Little Charlie

Posted on Posted in Brain Science, Continuing Education, Pain, Psychology

By Mary O’Brien, M.D.

Do you know what “Mitochondrial Deficiency Syndrome” is?  Most people don’t.  Unfortunately, that doesn’t stop them from weighing in on the case of little Charlie Gard.  Charlie is an 11-month old baby with a rare and devastating genetic disorder that precludes normal functioning of mitochondria.  Mitochondria are intracellular organelles that generate ATP (adenosine triphosphate).  In essence, ATP represents energy at the cellular level.  Without ATP, cells, especially brain and muscle cells, cannot function.  The most sensitive and vulnerable cells in the body are those of the cerebral cortex.  Little Charlie cannot see or hear or move or swallow or vocalize or think.  No one can know with absolute certainty, but he probably cannot “feel” anything at this point.  The word tragic is utterly inadequate.

The global media frenzy surrounding this heartbreaking situation is revealing and deeply disturbing.  Controversy sells, and unfortunately, the less people know, the more adamant and emotional they often become.  Those of us who have dealt with life and death situations for decades can help by elevating the level of conversation.  Some timeless principles are useful:

  • Embrace humility.  Never be afraid to say “I don’t know enough about this situation to have a well-informed opinion.” That would be refreshing.
  • Exercise the intellectual discipline to learn the facts involved.  In medicine, every patient is unique.  Arguments for or against life support or experimental treatments are pointless absent actual knowledge.
  • Resist the temptation to become emotional.  Unbridled emotions cause far more problems than they solve.  Try to be the voice of reason.
  • Try not to confuse or conflate the issues.  People in nearly every media outlet have tried to make the case about socialized medicine, cost control, parental rights, the British court system, the European Union, or theology.  The case of Charles Gard is about medical ethics.
  • Focus on principles, not personalities.  There is a colossal difference between saving life and prolonging death.  Remember, there is never a moral imperative to render futile care.

Primum non nocere.  (First, do no harm.)  There’s a reason that Solomon prayed for wisdom.

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Arthritis and Diet

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

older-black-woman-rubbing-her-hands-arthritisThere are more than 100 different types of arthritis, and, therefore, no single diet will work for every person with arthritis.  However, studies have found that green tea, green leafy vegetables, dried plums, and kiwi fruit are all vitamin-rich and have powerful antioxidant properties.  Diets which include large quantities of fruits and cruciferous vegetables have been shown to have a beneficial effect on preventing the development of rheumatoid arthritis.  In addition, it is clear that carrying extra weight can put significant stress on the joints, and even a small reduction in weight can have an effect on the severity of arthritis symptoms.  Studies have shown that losing weight can significantly ameliorate the effects of osteoarthritis.  Significant weight gain prior to age 35 — as well as excessive alcohol consumption — has been linked to the development of gout.

Other contributing factors are certain foods and nutritional supplements (vitamins, minerals, and omega-3 fatty acids) which may play a role in preventing and reducing symptoms in some types of arthritis, such as gout, osteoporosis, osteoarthritis, rheumatoid arthritis (RA), and reactive arthritis.  Fish oil, particularly when ingested in conjunction with a diet low in arachidonic acid, reduces inflammation in some patients with rheumatoid arthritis.   Regular intake of fish has been shown to have a beneficial effect.  Consumption of excessive dietary fat, however, appears to exacerbate arthritis symptoms.

WEIGHT LOSS AND THE ARTHRITIS PATIENT

Weight loss for overweight arthritis patients is very important for several reasons.  First, as mentioned previously, loss of even a few pounds can significantly reduce stress on weight-bearing joints.   Research demonstrates that exercise and combined weight loss — as well as exercise regimens — result in decreased pain and disability and increased performance levels in patients with osteoarthritis.  Biomechanical data suggest that exercise in combination with diet may also result in improved gait when compared with exercise alone. Secondly, patients of all ages who have arthritis are much healthier, have an improved sense of well-being, and are less likely to suffer arthritis-related depression when they follow a nutritious, well-balanced diet.  The Arthritis Foundation recommends following a balanced diet that includes plenty of fruit, vegetables, and whole-grain products, while limiting consumption of sugar, salt, and saturated fat (i.e., a diet low in fat, high in fiber, and low in sugar).

By Mary O’Brien, MD

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Neck Pain: An Introduction

Posted on Posted in Continuing Education, Elder Care, Homestudy, Pain, Seminars, Webinars

Rear view of a young man holding her neck in pain, isolated on white background, monochrome photo with red as a symbol for the hardening

By Raj Hullon, MD

Almost everyone has experienced neck pain of some sort during his or her lifetime — and for good reason.  One of the most common causes of such pain is poor posture.  Simple activities such as reading, especially in bed — or sleeping on a pillow that may either be too low or too high — can cause neck pain.  Other activities that can cause neck pain include bending over a desk for hours, maintaining poor posture while watching TV, and positioning a computer monitor either too high or too low.  The key is always to maintain the neck as close to a neutral position as possible.

The best medical care, however, begins with a crucial question:  What is the most serious problem this could be?  Neck pain can be referred from multiple anatomical structures as a result of developmental processes in the embryonic stage.  Serious cardiovascular, neurologic, infectious, or neoplastic etiologies must be considered before attention is focused on common musculoskeletal disorders.

Chronic neck pain is prevalent in Western societies, with about 15 percent of women and 10 percent of men suffering from it at any given time.  People with physically demanding jobs requiring neck flexion and awkward lifting are at high risk of developing chronic neck pain.  It is also common among health care professionals, particularly affecting nurses who are constantly involved in handling tasks that involve reaching, lifting, and pulling.  Dental professionals who work long hours bending over their patients also suffer from neck pain because of postural demands.

The pain is often muscular or ligamentous in origin and is usually self-limited although the pain can be persistent.  Pain is transmitted through nerve endings in the various ligaments and muscles of the neck, vertebral joints, and the outer layer of the intervertebral discs.  When these structures are irritated, strained, or inflamed, pain is felt in the back of the neck, may spread toward the shoulders, and is commonly felt between the shoulder blades.

The natural healing processes result in improvement in almost all cases.  In fact, the pain from serious neck injuries such as fractures, dislocations, and most cervical spine surgeries often resolves after a few weeks or months.  There is usually little if any correlation between neck pain and the degenerative changes that are commonly seen on X-rays.

Neck strain or sprain is the most common type of injury to motor vehicle occupants treated in U.S. hospital emergency departments.  Whiplash injuries can be serious in certain situations.  Severe damage to the spinal cord can be fatal.

Sports and athletics are also common sources of injury to the neck region and should be a particular concern for the younger adult population.

Another common offender is carrying unbalanced loads, such as a heavy briefcase, luggage, or a shopping bag. A careful history is often required to identify such factors as playing a role in neck and shoulder pain.

 

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A Brief History of Pain

Posted on Posted in Continuing Education, Homestudy, Pain, Seminars, Webinars

first-aid-908591_640By Dr. Mary O’Brien, MD

Early humans explained the mystery of pain by associating it with evil, magic, and demons. Relief was the responsibility of sorcerers, shamans, priests, and priestesses, who treated their clients with herbs and rituals.

On stone tablets, ancient civilizations recorded accounts of pain and the treatments used, including pressure, heat, water, and sun. The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system were involved in the perception of pain. During the Middle Ages and into the Renaissance, evidence began to accumulate supporting these theories. Leonardo da Vinci and his contemporaries came to see the brain as the central organ responsible for sensation, with the spinal cord transmitting sensations to the brain.

In the 19th century, pain came to dwell under a new domain—science—which paved the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. In the late 1800s, research led to the development of aspirin, to this day the most commonly-used pain reliever. Before long, anesthesia—both general and regional—was refined and applied during surgery.

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. There are two basic categories of pain, acute and chronic, and they differ greatly.

Acute pain usually results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly—for example, after trauma or surgery—and may be accompanied by anxiety or emotional distress. The cause of acute pain can generally be diagnosed and treated, and the pain is self-limiting—confined to a given period of time and severity. In some instances, it can become chronic.

Chronic pain is widely believed to represent a disease in and of itself. It persists over a longer period of time than acute pain and is resistant to most medical treatments. Chronic pain often persists longer than three months, or longer than expected for normal healing. It can be made much worse by environmental and psychological factors. It can—and often does—cause severe problems for patients, as pain signals keep firing in the nervous system for weeks, months, or years. There may have been an initial mishap such as a sprained back or serious infection, or there may be an ongoing cause of pain such as arthritis, cancer, or infection. However, some people suffer chronic pain in the absence of any past injury or evidence of illness.

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Essentials of Hypothermia

Posted on Posted in Continuing Education, Homestudy, Pain

 

tyrol-69661_640Surviving hypothermia after being left for dead in the wilderness makes an interesting story line in the movies.  In real life, hypothermia kills over a thousand people each year in the United States alone.  Knowing how to recognize it and treat it (or better yet, prevent it) can save lives.

Systemic hypothermia involves a core body temperature below 35 degrees Celsius.  Accurate measurement is crucial and the core temperature probe must be able to measure as low as 25 degrees Celsius.  Resuscitative measures must always be continued until the patient’s core temperature is clearly over 32 degrees Celsius (unless there are obvious fatal injuries).  As every physician, nurse, and first responder has been taught, “you’re not dead until you’re warm and dead.”

Susceptibility to hypothermia is increased by extremes of age, heart disease, exhaustion, hunger or malnutrition, dehydration, hypoxia, immobility, intoxication with drugs or alcohol, low body mass, contact with moisture or metal, and loss of consciousness.  Even in the movies, victims of hypothermia try desperately to stay awake and keep moving.

Clinical signs and symptoms of hypothermia vary based on the patient’s underlying status.  In general, however, there are four stages:

  • Stage I- CBT (core body temperature) is between 32 degrees Celsius and 35 degrees Celsius.  The patient is shivering and may be losing good judgement and coordination; still conscious and hemodynamically stable.
  • Stage II – CBT is between 28 degrees Celsius and 32 degrees Celsius.  Shivering stops, pulse slows, and pupils dilate.  Reflexes slow and “cold diuresis” develops as a result of renal dysfunction and low levels of ADH (antidiuretic hormone). Eventually, this will lead to hypovolemia and shock.  The patient becomes increasingly confused and lethargic.
  • Stage III-CBT is between 24 degrees Celsius and 28 degrees Celsius. Vital signs may still be present, but the risk of cardiac arrest increases dramatically, and the patient is now unconscious.
  • Stage IV – CBT is less than 24 degrees Celsius.  Vital signs are absent.  There is coma, loss of reflexes, asystole or ventricular fibrillation and rigor mortis. The patient appears dead but may still be salvageable.

The cornerstone of treatment in hypothermia is rewarming.  Rapid assessment with support of airway, breathing, and circulation must occur almost simultaneously.  All cold, wet clothing should be removed and replaced with warm, dry clothing and blankets.  The patient’s head should be covered and every effort must be made to prevent additional heat loss.  In general, raising core body temperature by 1 degree Celsius per hour is safe.  Giving warmed IV fluids (normal saline at 45 degrees Celsius) may be helpful.

Great care and caution must be used when moving or transporting a hypothermic patient.  The combination of vasoconstriction, hypovolemia, and return of cold peripheral blood to the central circulation can cause ”core temperature after drop.”

This phenomenon, combined with lactic acidosis, can precipitate potentially fatal arrhythmias known as “rescue collapse.”  This is where real life must break with the movies.  Dramatic scenes where the rescuer frantically rubs and massages the victim’s extremities may be riveting, but they’re also wrong.

Preventing hypothermia is much easier than treating it.  When in doubt, rely on the old adage: Keep warm, keep dry, and keep moving.

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The Mystery of Pain: Acute vs Chronic Pain

Posted on Posted in Brain Science, Continuing Education, Pain, Psychology, Seminars, Webinars

By Michael Howard, Ph.D.

Early humans explained the mystery of pain by associating it with evil, magic, or demons. Relief was the responsibility of sorcerers, shamans, priests, and priestesses, who treated their clients with herbs and rituals.

Ancient civilizations recorded on stone tablets accounts of pain and the treatments used, including pressure, heat, water, and sun. The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system were involved in the perception of pain.pain

During the Middle Ages and into the Renaissance, evidence began to accumulate supporting these theories. Leonardo da Vinci and his contemporaries came to see the brain as the central organ responsible for sensation, with the spinal cord transmitting sensations to the brain.

In the 19th century, pain came to dwell under a new domain—science—which paved the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. In the late 1800s, research led to the development of aspirin, to this day the most commonly-used pain reliever. Before long, anesthesia—both general and regional—was refined and applied during surgery.

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. There are two basic categories of pain, acute and chronic, and they differ greatly.

Acute pain usually results from disease, inflammation, or injury to tissues. This type of pain generally comes on suddenly—for example, after trauma or surgery—and may be accompanied by anxiety or emotional distress. The cause of acute pain can generally be diagnosed and treated, and the pain is self-limiting—confined to a given period of time and severity. In some instances, it can become chronic.

Chronic pain is widely believed to represent a disease in and of itself. It persists over a longer period of time than acute pain and is resistant to most medical treatments. Chronic pain often persists longer than three months, or longer than expected for normal healing. It can be made much worse by environmental and psychological factors. It can—and often does—cause severe problems for patients, as pain signals keep firing in the nervous system for weeks, months, or years. There may have been an initial mishap such as a sprained back or serious infection, or there may be an ongoing cause of pain such as arthritis, cancer, or infection. However, some people suffer chronic pain in the absence of any past injury or evidence of illness.

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What is Fibromyalgia?

Posted on Posted in Continuing Education, Homestudy, Pain, Seminars, Webinars

alone-62253_640By Nikita Katz, M.D., Ph.D.

The word “fibromyalgia” is derived from the Latin roots “fibro” (connective tissue), “my” (muscles), “al” (pain), and “gia” (condition of).  As a syndrome, fibromyalgia is composed of a specific, often complex, set of signs and symptoms that complicate diagnosis and treatment. Before official recognition as a disorder by the American Medical Association (AMA) in 1987, fibromyalgia was considered a “wastebasket” diagnosis, but lately there has been a “paradigm shift,” and fibromyalgia is being recognized as a true illness and a major cause of disability.

Fibromyalgia is a disorder characterized by chronic widespread musculoskeletal pain with associated fatigue, insomnia, and multiple somatic complaints such as stiffness, headache, and chest pain, with no evidence of disease.  It occurs mostly in women but does occur in men.  Most of the pain involves several tender points in the body, which are targeted areas where people with fibromyalgia feel an exaggerated sense of physical pain upon the slightest application of pressure. Fibromyalgia is neither degenerative nor progressive, and there is no inflammation.  In fact, it used to be called fibrositis, but the name was changed to fibromyalgia when evidence showed no inflammation in the disease process.  It is non-articular, meaning it does not involve the joints, and there is no swelling in the joints or tissues.  Descriptions of conditions consistent with what we now call fibromyalgia have been found in the medical literature as far back as the early 17th century.

Although there is no cure for fibromyalgia, several treatments can alleviate the multiple symptoms of this complex disorder, thus making it easier for patients to live a near-normal life.  Treatments include pharmacological interventions, dietary counseling, alternative medicine, relaxation techniques, and moderate exercise.  Many authors recommend combined management of fibromyalgia rather than just one treatment alone.

Fibromyalgia is not a life-threatening, deforming, or progressive disease.  Although lack of proper treatment may lead to the illusion of disease progression, this illusion is not supported by scientific evidence.  Compensation of sleep deprivation and physical reconditioning should, at least in some patients, lead to reversal of the disease or improvement of function and reduction of pain.

Numerous modalities available can reduce pain and other debilitating symptoms; these include electrotherapy, cryotherapy, and therapeutic heat. The clinician should teach patients how and when to use therapeutic modalities as part of their maintenance program. A multidimensional clinical approach including behavioral therapy, exercise, and pharmacological intervention is essential.

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Migraines In Women

Posted on Posted in Continuing Education, Homestudy, Pain, Seminars

woman-565132_640Migraine headaches are usually characterized by throbbing, severe pain (usually on one side of the head), an upset stomach, and — sometimes — disturbed vision.

Migraines were recognized as early as the 7th century BC—when the usual treatment involved trephining, or creating a hole in the skull to relieve the headache pressure, and release the “evil spirits or demons” thought to be causing the pain.

Women are three times more likely than men to suffer from migraine headache. Hormonal changes and the patient’s stage of life may play a role in women’s higher susceptibility to migraine. Even in ancient history, women with migraines probably greatly outnumbered men with the disorder.

Throughout history, a number of myths about migraine in women have flourished. Migraines in women were often attributed solely to PMS (pre-menstrual syndrome) or hormonal changes, such as those that occur during menopause. Another myth was that headaches in general — and headaches in women, in particular — were due to psychological problems, rather than being a biological condition. Consider some facts about migraines and women:

  • In the United States, almost nine million women suffer from migraines each year, and over three million have more than one migraine attack per month.
  • Sixteen out of every 100 women suffer from migraine headaches.
  • The highest prevalence for migraine in women occurs between the ages of 35 and 45, a time when many women are at the height of their professional careers and have the most family responsibilities and social obligations.
  • Half of all women with migraines report having 24 or more migraine attacks each year, and over 25 percent report having such headaches every week.
  • In women who have migraines, 60 percent experience headaches during menses as well as at other times of the month. Just 14 percent of women have migraine pain only during their menstrual period.

Headache is one of the most common conditions seen by clinicians today. Migraine headaches can be especially troublesome for patients and can cause symptoms that include significant pain as well as neurologic symptoms. Fortunately, there are now many effective treatments for migraine and other headaches, including medications and lifestyle changes.

In women with migraines, hormonal changes can play a significant role in the severity of symptoms. Thus, successful treatment of female migraineurs requires knowledge of neuro-endocrine changes from menarche to menopause. With such knowledge, clinicians can help female patients find relief from this challenging condition.

A thorough medical history and careful physical examination are essential to rule out less common but serious causes of headache. The best treatment always starts with the right diagnosis.

INR offers continuing education courses such as Women’s Health: Migraines and Headaches.  Click below for this and more from our library.

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Rheumatic Diseases

Posted on Posted in Continuing Education, Homestudy, Pain

marseille-142394_640Rheumatic diseases have been with us for centuries—since at least the early Bronze Age. According to the Arthritis Foundation, American Indians living in 3000 BC showed signs of rheumatoid arthritis.

The symptoms of rheumatic disease were first formalized in 1680 by the British physician, Thomas Sydenham. At the time, he described the pain of acute gout flares in his patients as “so exquisite and lively…it cannot bear the weight of bedclothes nor the jar of a person walking into the room.”

As Sydenham observed, many types of arthritis can be painful and even disabling. Today’s treatments, including new pain relievers, Disease Modifying Anti-Rheumatic Drugs (DMARDs), and biologic agents can help reduce symptoms and slow the progression of arthritis. Surgery can repair joints, bones, and tendons damaged by arthritic disease. Lifestyle changes, including diet, exercise and assistive devices, make it possible for many people with arthritis to live fully functional, even active lives.

Approximately 50 million U.S. adults—about one in five—have physician-diagnosed arthritis. However, nearly one in three adults have arthritis or chronic joint symptoms. Arthritis is the most prevalent cause of disability in the United States, and results in upwards of 66 million physician visits each year.

As the population ages, the incidence of arthritis will rise dramatically and is expected to increase to 67 million by 2030.  Arthritis will create an important public health problem as well as tremendous personal suffering.  The societal costs of arthritis are immense. The estimated yearly medical care costs for arthritis total nearly $81 billion in the U.S. The cost of medical care plus lost work productivity is even larger—approximately $128 billion.

In general, rheumatic diseases are characterized by:

  • Inflammation
  • Redness and/or heat in a joint
  • Swelling in the joints
  • Recurring or constant pain
  • Decreased range of motion in joints
  • Stiffness
  • Fever, weight loss, and fatigue — in some types of rheumatic disease.
  • Loss of function in connective tissues
  • Involvement of joints, tendons, ligaments, bones, and muscles

Rheumatic diseases are systemic and often involve internal organs.  Though arthritis is a growing problem by virtue of demographics, the disease is also becoming increasingly manageable. With improved screening and today’s treatments, people with arthritis may live active, independent lives. Every effort should be made to protect sleep, preserve functional independence, and provide for effective pain management.

New research is also pointing the way toward increased knowledge about the causes of arthritis, which will ultimately improve available treatments. Appropriate diagnosis, comprehensive treatment, and prevention of complications will continue to improve in the next decade, enhancing quality of life for millions.

Rheumatic Disease and Arthritis are just two of the topics covered in our Homestudy Courses.  Click below for more information.

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Knee Pain

Posted on Posted in Continuing Education, Homestudy, Pain

Knee PainBy Rajinder Hullon, MD, JD

Knee pain is one of the most common complaints seen in outpatient medical-treatment centers. This disorder affects 20 percent of our population and is the fifth most common health complaint, accounting for millions of doctor visits each year.

Physicians treat knee pain more frequently these days for a number of reasons. Better health care options and availability have resulted in people living longer. Because the knee joint is one of the key weight-bearing joints in the body, it is subject to more wear and tear with age. Older people are more likely to suffer from some degree of knee pain.

The nationwide problem with obesity has also contributed to the increasing frequency of knee complaints. More stress is placed upon the knee joint the heavier a person is. At some point, the knee joint will be unable to support this stress, and surgical intervention may be required.

Preventing Knee Injuries

As everyone knows, an ounce of prevention is worth a pound of cure. In the case of the knee joint, the American Academy of Orthopedic Surgeons and the American Orthopedic Society for Sports Medicine offer these suggestions to avoid pain or injury:

  • Stay in shape. Good general conditioning helps control or prevent knee pain, particularly patello-femoral pain. Overweight individuals may need to lose weight to prevent excessive stress on the knees. Doctors recommend a 5-minute warm-up before running or beginning any other exercise.
  • Stretch. Stretching is a good warm-up technique before and after any exercise. When performed in the prone (face down) position, it helps maintain the flexibility of the ligaments, muscles, and tendons within the knee joint.
  • Increase training gradually. Work up gradually and avoid sudden changes in the intensity of exercise.
  • Use proper running gear. Running shoes should have good shock absorption and quality construction. Be sure shoes fit properly and are in good condition. If you have flat feet, you may need shoe inserts. Running shoes should be replaced every 3-4 months if used consistently.
  • Use proper running form. Lean forward and keep the knees bent. Also, try to run on a clear, smooth, and reasonably soft surface. Never run straight down a steep hill. Walk down it, or run in a zig-zag pattern.

Since there can be many different causes for such pain, the clinician must take great care to make an accurate diagnosis in order to ensure proper medical and/or surgical treatment.

Many knee pain cases also involve overuse or injury from sporting activities. In these situations, individuals should be aware of the importance of warm-up exercises and, and if pain arises, the need to seek early treatment to avoid permanent or disabling knee injury.

Of course, if you experience knee pain, the best thing you can do is see a doctor, and remember that if you’ve been diligent about exercise for a long time, a week off for rest and recovery might be the best thing you can do, whether you’ve come down with an injury or not.

INR (Institute for Natural Resources) offers continuing educations courses that cover many medical conditions including knee pain.

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