Monday, December 31, 2007

December Pain-Blog Carnival | How To Cope With Pain Blog

Welcome to December's Pain-Blog Carnival…  the best pain articles in December.  Many of you are on vacation for the holidays, so you'll have this whole week to enjoy these great pain articles!  I'll be back next Monday with a series on learning new pain management techniques and how to help yourself regularly use those that work.  Think of it as your at-home tutorial in pain management!

What's Positive Psychology?  Healthskills:  Skills for Healthy Living looks at how optimism, resilience and adaption can help people with pain.

Do doctors abide by the Hippocratic oath when treating pain disorders such as fibromyalgia?  A very interesting post at Living with Fibromyalgia looks at how well (or poorly!) doctors work with patients when there aren't a lot of answers.

Laurie at A Chronic Dose reflects on the precarious relationship between stress and illness in her own life, especially during the last few weeks of grades due, moving, project deadlines…  does that sound familiar to anyone??

Winter is infection time… colds, the flu, bronchitis.  Fighting Fatigue shares with us why patients with pain may have more infections, and how to prevent and treat them.

Holiday invitations are sometimes challenging for those of us with pain… accept?  decline?  feel guilty?  overdo it?  Somebody Heal Me: The Musings of a Chronic Migraineur gives some sound advice for any time of year in 7 Tips for Social Plans When You're Chronically Ill.

Another great post that looks at how to best enjoy the holiday season (or any hectic time!) even with pain is this one from Nickie's Nook.  Some great suggestions are here!

CRPS-RSD A Better Life looks back over the year at what she's learned to help with chronic pain.

Welcome to Andrea's Buzzing About, a new submitter to the carnival.  Check out her thoughts about the experience of pain that doesn't go away - a description of the chronic pain experience in a nutsehll.

Emotional support and early treatment for soldiers in pain is crucial, shows a study by researchers at Johns Hopkins.  Troops treated in Iraq were much more likely to return to active duty, compared to those evacuated to another country's facility.  Psychology of Pain provides the interesting story.

Sufferer of RSD writes about needing to find new things in life to love.  "The things I once loved to do are now a shadow in the back of my mind.  This post reflects on finding new things to do that closely resemble my shadows."

Working with Chronic Illness looks at going into business for yourself.  Good idea?  Risky?  Check out her post to see.

Counting Sheep, a nurse anesthetist, reflects on the science and the art of treating and preventing pain.

Friday, December 21, 2007

The Corpus Callosum

The Corpus Callosum is an occasional journal of armchair musings, by a suburban, reality-based, slightly-left-of-center guy, who reserves the right to be highly irregular at times. Topics: social commentary, neuroscience, politics, science news. Mission: to develop connections between hard science and social science, using linear thinking and intuition; and to explore the relative merits of spontaneity vs. strategy.

NeuroLogica Blog » Does Acupuncture Work or Not?

Acupuncture is a complex "alternative" modality because something physical is actually happening - thin needles are being stuck through the skin and manipulated. So it is therefore not impossible that a physiological response is happening. It is much easier to comment on things like homeopathy and therapeutic touch where literally nothing physical is happening and the plausibility for any benefit is therefore zero. So if I try to answer the question in my title, much explanation and qualifications are required. To answer this question - does acupuncture work? - my current best answer based upon available evidence is a qualified no. This answer is not changed by the most recent study of acupuncture that is being touted by the press as evidence that acupuncture works. (Here is the original study, but a subscription is required.)

Let's first look at this study, which was a German study of acupuncture for back pain. Dr. Heinz Endres studied 1,100 randomized patients with three treatment arms. The first received standard therapy - massage, anti-inflammatories, and heating pads. The second received acupuncture, and the third received sham acupuncture where the needles were inserted but not deeply, and not manipulated, and not in traditional acupuncture points. The study found 47% improvement in the acupuncture group, 44% in the sham acupuncture, and 27% in the standard therapy group after 6 months.

This single study, even taken just by itself, falls far short of demonstrating that acupuncture works. And of course we have to place it in the context of plausibility and the entire acupuncture literature. We also have to identify appropriate sub-questions.

First let us consider the difference between "real" acupuncture and "sham" acupuncture. Acupuncture is based upon the ancient and superstitious pre-scientific notion that there are lines of mysterious life energy (chi) flowing through our bodies, and that the flow of this energy is responsible for health and illness. Acupuncture is supposed to free up blockages in the flow of chi energy. I grant this idea a scientific plausibility of zero - meaning we can safely discard it.

What does the evidence show for the chi theory of acupuncture? The evidence is overwhelmingly negative, and this study supports this negative consensus. Most well-designed studies that compare traditional and sham acupuncture show no difference between the groups. In this study the two groups were 47% and 44% respectively. This means that it does not matter where you put the needles or if you manipulate them in any way - that's because there are no lines of flowing chi.

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Respectful Insolence

Respectful Insolence is a repository for the ramblings of a pseudonymous surgeon/scientist concerning medicine and quackery, science and pseudoscience, history and pseudohistory, politics, and anything else that interests him (or pushes his buttons).

Wednesday, December 19, 2007

Cold feeling traced to source

Cold feeling traced to source

For the first time, neuroscientists have visualized cold fibers – strands reaching from sensory neurons near the spinal cord to nerve endings in the skin tuned to sense different types of cold. The study and pictures appear in the Dec. 19 issue of the Journal of Neuroscience.

Surprisingly, given the highly diversified sensory system and the range of sensations studied – harmless cool, stinging cold, soothing coolness – the fibers lead back to one place in the neuron: a protein known as TRPM8 that relays a cold signal up the spinal cord to the brain.

The idea of a cold fiber is simple. When the dentist chills a tooth with compressed air, the fiber carries a signal from nerve ending to sensory neuron. The neuron relays the signal to the brain, and the patient shivers.

In practice, said USC study leader David McKemy, "no one's actually seen a specific cold fiber."

McKemy's study solved that problem by genetically engineering mice in which neurons that express TRPM8 molecules also included a fluorescent tracer that lights up the fibers.

McKemy's study provides the first visualization of cold-sensing, TRPM8-expressing neurons. Previous studies had shown that mice lacking TRPM8 lose much of their cold sensitivity (video available at ).

Humans and other mammals appear to share the same mechanism, McKemy said.

By following the fluorescent cold fibers, the researchers added to the evidence that TRPM8 is involved in several types of cold sensing. In teeth, the distinct nerve endings involved in the initial shooting pain and the subsequent dull ache both lead back to TRPM8, McKemy said.

Sensations such as the pleasant coolness of menthol, the sting of ice on the skin, the heightened cold sensitivity after an injury and the soothing cool of some pain relief lotions also involve TRPM8, he added.

Removing TRPM8 does not eliminate all sensitivity to all types of cold. Extreme cold not only activates TRPM8 but also burns the skin, turning on many other warning circuits.

"Cold is going to be activating these cool and cold cells that likely are the ones we're studying in this paper as well as activating these neurons that are probably responding to tissue damage," McKemy said.

"So your higher cognitive centers are processing a cool signal and a pain signal, and so we get cold pain.

"As with anything with biology, it's not as simple as you would think."

McKemy was the lead author of a landmark 2002 study, published in Nature, that first identified the cold-sensing role of TRPM8.

One larger goal of such research is to understand the molecular mechanisms of sensation, in the hope of developing better drugs for relief of chronic pain states, such as arthritis and inflammation.

"If we understand the basic nuts and bolts of the molecules and neurons and how they detect pain normally," McKemy said, "then perhaps we can figure out why we detect pain when we shouldn't."

Pain Treatment In The Field: Good For Soldiers' Comfort And Better For Rebuilding Troop Strength

Pain Treatment In The Field: Good For Soldiers' Comfort And Better For Rebuilding Troop Strength

ScienceDaily (Dec. 18, 2007) — Noncombat-related acute and recurrent chronic pain are the leading causes of soldier attrition in modern war, with the return-to-duty rate as low as 2 percent when these soldiers are treated outside the theaters of operation. However, that rate jumps to 95 percent when troops and officers are treated and managed for pain in the field of instead of being sent elsewhere for therapy, according to a new study from a Johns Hopkins anesthesiologist.

"The main factor seems to be rapid diagnosis and treatment of pain syndromes," says study co-author Colonel Steven Cohen, M.D., of the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine.

"Establishing pain treatment centers in combat areas gets care to soldiers fast and could dramatically increase the military's ability to maintain troop levels and succeed militarily in places like Iraq," says Cohen.

The report, appearing in the December issue of Anesthesiology, shows that 107 out of 113 soldiers suffering from noncombat-related pain were able to return to duty after being treated at the Ibna Sina Hospital in Baghdad between October 2005 and September 2006.

In contrast, a previous study by Cohen and colleagues showed that of 162 soldiers with similar kinds of pain evacuated from Iraq for treatment at Walter Reed Army Medical Center in Washington, D.C., or the Landstuhl Regional Medical Center in Germany between April 2003 and July 2004, only three returned to active duty.

Noncombat pain was defined in both studies as conditions resulting from such things as physical training, sports and accidents.

Among those patients treated in the field, sciatica (leg pain and/or tingling, numbness or weakness that travels from the low back through the buttock and down the large sciatic nerve in the back of the leg) accounted for 55.7 percent of the cases; noncardiac chest pain, 11.5 percent; arm pain from a herniated disc in the neck, 7.1 percent; groin pain, 7.1 percent; leg pain, 7.1 percent; low back pain without leg symptoms, 6.2 percent; arm pain unrelated to a herniated disc, 1.8 percent; and neck pain/headache, 1.8 percent. All of the patients were seen within 72 hours of their initial complaints by anesthesiologists who are pain specialists.

In the first study done in soldiers who were evacuated for treatment, the most common complaints were sciatica, low back pain, leg pain and arm pain. The majority of these cases did not receive definitive treatment until a few weeks after their initial complaints.

Treatments for both sets of patients were similar and included epidural steroid injections, trigger point injections, lumbar interarticular facet blocks, groin blocks, corticosteroid injections, as well as nonsteroidal anti-inflammatory drugs, neuropathic pain drugs, muscle relaxants and opioids.

"Early intervention is almost always associated with better outcomes," says Cohen. "The longer a pain complaint goes untreated, the worse the prognosis."

Cohen says it is also more difficult to re-deploy soldiers once they are medically evacuated, for both logistical and psychological reasons. "Soldiers who stay with their units build on the strong ties with those units and wish to remain. Those bonds weaken when military personnel are stateside with their families, making theses soldiers even less amenable to returning to the field," he says.

Cohen co-authored the study with Major Ron L. White, M.D., an anesthesiologist at the Uniformed Services University of the Health Sciences in Washington, D.C. White serves in the United States Army and Cohen is in the United States

Post-Op Rx: Get a Massage - TIME

Post-Op Rx: Get a Massage
Tuesday, Dec. 18, 2007

If you know someone who's getting ready to go into surgery, consider holding off on the get-well-soon balloons, and start looking for a good massage therapist instead. A new study published in the December issue of the American Medical Association's Archives of Surgery found that massage, in conjunction with regular pain medication, significantly improved patient pain and anxiety after major surgery.

The study, which was funded by the Department of Veterans Affairs (VA) and lasted from 2003 to 2005, involved 605 veterans — most of whom were white men with an average age of 64, who had chest or abdominal surgery. All patients received routine postoperative care. Two experimental groups, however, received additional individual attention from a massage therapist: One group got a 20-minute visit, during which the patient and the therapist talked but no massage was given, and another group received a 20-minute back massage for up to five days following their operations. The massage group, the study found, reported markedly less intense and less unpleasant pain and less anxiety than patients who got standard pain medication or individual attention but no massage. Dr. Daniel Hinshaw, a surgeon in the VA Ann Arbor Healthcare System and one of the study's co-authors, says that when asked a day after surgery, some patients reported that massage delivered about as much pain relief as a dose from a morphine drip. Hinshaw suggests that massage functions by creating a competing sensation to block pain or by generating endorphin-like chemicals in the body, which reduce pain and promote a sense of well-being. He also notes the crucial — and often forgotten — role of touch in medicine: Human touch can help alleviate anxiety and ease pain. "Patients crave contact," says Hinshaw. "They want some kind of comforting presence."

The new findings come at the end of an eventful year for massage-therapy research. In March, researchers at the University of California, San Francisco, School of Medicine's Osher Center for Integrative Medicine published a study finding that Swedish massage, shiatsu foot massage, and acupuncture helped reduce pain and depression in postoperative cancer patients. An October 2007 pilot study by the Mayo Clinic showed that massage significantly reduced pain levels in patients recovering from heart surgery, prompting the internationally renowned treatment center to bring a full-time massage therapist onboard. That same month, the American Massage Therapy Association published a survey in which 30% of all respondents who had received a massage in the last five years did so for medical reasons — including pain relief, injury recovery, soreness and control of migraines — compared with 22% who sought relaxation and 13% who were merely indulging themselves. The survey also found that nearly one in five respondents had discussed massage therapy with their doctors, and of those who did, the majority said their doctors had encouraged them try it.

Of course, massage is hardly a breakthrough treatment — it's been used for centuries in traditional healing. The UCLA Center for East-West Medicine, which has incorporated traditional Chinese medicine (TCM) and western medicine since 1993, uses massage for most of its 14,000 or so patients each year, who come for treatment of conditions ranging from post-surgical pain to migraines. Dr. Ka-Kit Hui, the center's founder and director, says massage is safe and effective across the board, reflecting one of the core concepts of TCM: using physical methods to help stimulate the body to correct its own chemical flow. "Muscle spasm is not normal," says Hui, whether it's in a recovering cancer patient or an insomniac. "When you take care of that, other conditions can be helped."

It was, in fact, a moment of medical nostalgia that prompted the pilot study that became the foundation for the VA trial. Recalling his days as a surgical resident in the 1970s, Hinshaw says older nurses would regularly give massages to frail, elderly patients prone to delirium on postoperative drugs. The treatment — standard at the time — helped those patients. "But now most of the nurses who practice it are retired," he says, and, now, medical training adheres more strictly to quantitative means of evaluating patient progress. So, patients' individual concerns and worries are sometimes swept aside in the process, preventing them from receiving proper pain diagnoses, while certain holistic treatments are less likely to be accepted than conventional western practices. "We'd have to stop practicing medicine" if everything doctors did required back-up by evidence from trials, says Hinshaw, "but we have that evidence for massage. We can see a real effect."

Getting the larger health care system to buy into the idea is another matter. Currently some, but not all, U.S. health insurers cover some form of massage therapy. To gain broader, more mainstream acceptance, Hinshaw says, the treatment will have to prove cost-effective as a pain-reliever. But, in most hospitals, where patients are cycled through intensive care units in a "highly choreographed sequence," there's not a lot of time or imagination to squeeze in massage therapy. Further research, perhaps showing that massage can shorten patients' hospital stays or reduce their analgesics use, may prompt hospitals to include massage more routinely in patient care. In the meantime, patients who want the health industry to think outside the box have to say so: If patients demand massage, Hinshaw says, "hospitals will listen.",8599,1695812,00.html

Thursday, December 06, 2007

MDC Scientists Reveal Role of Gene in Sensitivity to Thermal Pain

The skin is the largest human sensory organ. What is not fully understood is how the skin responds to stimuli, especially to pain. Research by Nevena Milenkovic, Christina Frahm, Professor Gary Lewin and Dr. Alistair Garratt of the Max Delbrück Center for Molecular Medicine (MDC) in Berlin-Buch, Germany, has now demonstrated that Stem Cell Factor (SCF) and its receptor, c-Kit, play a central role in tuning the responsiveness of sensory neurons to heat stimuli. "As yet, c-Kit is the first example of a single gene being required for normal noxious heat sensitivity of C-fibers," according to the neurobiologists. Their paper has just been published online in Neuron *.

Depending on the size of the individual, there are between 1.5 and 2 million sensory receptors in the skin which are sensitive to pain, pressure (touch) and temperature. These specialized sensory neurons, also called nociceptors, detect painful thermal and mechanical stimulation of the skin and transmit the information to the brain, where it is processed and consciously experienced as pain.

"About 40 percent of the skin's sensory receptors are responsible for the perception of pain," Professor Lewin explained. "Receptors sensitive to touch account for only ten percent." This disproportionate distribution of receptors specialized in pain and touch underscores the significance of pain sensitivity. "Without pain receptors," Professor Lewin and Dr. Garratt pointed out, "we would quite probably die of unnoticed injuries at an early age."

Pain threshold for heat is lowered 
Pain receptors are nerve endings – nerve fibers that inform the brain about skin injuries. These nerve fibers have different cell surface receptors. One of these is c-Kit, which the MDC researchers investigated more closely.

To study the characteristics of the receptor in more detail, the MDC researchers bred mice lacking c-Kit. Experiments attempting this were already carried out in the 1950s, but the mice died of anemia very quickly. It was not until the advent of transgenic technology that this problem could be circumvented. Dr. Garratt administered the gene for erythropoietin (Epo) to the mice. Epo is a hormone which stimulates the production of red blood cells. As a result, the mice are no longer anemic and have a normal life expectancy.

If the mice – lacking c-Kit but equipped with extra copies of the Epo gene – are exposed to temperatures that are normally extremely painful, they at first do not react. It takes a temperature of about 6 degrees Celsius (°C) above the normal pain threshold of approximately 41 - 50°C for the animals to respond to the stimulus. C-Kit is activated by Stem Cell Factor (SCF), a ligand that it is expressed in the skin. Therefore, the scientists conclude that also when the skin is injured, SCF is released and stimulates c-Kit, leading to a reduced pain threshold for heat. Consequently, sensitivity to heat in the affected area is elevated, as the MDC scientists observed after injection of SCF and measuring paw withdrawal latencies to a heat stimulus. Professor Lewin explained how this works. "It's like having a sunburn – even lukewarm water becomes painful," he said.

Cancer drug Gleevec (Imatinib) blocks c-Kit – heat sensitivity decreases 
The researchers attained similar results by administering Gleevec (imatinib), a drug that a few years ago revolutionized the treatment of breast cancer, leukemias and gastrointestinal stromal tumors, but also can apparently alleviate pain. Gleevec blocks a specific group of proteins to which c-Kit also belongs.

In the experiments, sensory fibers of wild-type mice expressing c-Kit that were given Gleevec showed the same properties as those of mice that did not express c-Kit: the pain threshold for heat was clearly higher in wild-type mice treated with Gleevec. They were able to bear higher temperatures than the control mice not given Gleevec. Next, the researchers want to investigate if Gleevec really can alleviate pain in patients.

Saturday, December 01, 2007

Robert Craig 'Evel' Knievel October 17, 1938 - November 30, 2007

"If you don't know about pain and trouble, you're in sad shape. They make you appreciate life."

Friday, November 30, 2007

November Pain-Blog Carnival: Thankfulness | How To Cope With Pain Blog

How to Cope with Pain is now offering a monthly Pain-Blog Carnival during the last week of every month, to include each month's best posts.  November's carnival is now posted.  New bloggers are always welcome to contribute.

In honor of the American tradition of Thanksgiving which was celebrated last week, this month's Pain-Blog Carnival theme is thankfulness.  I'm thankful for the great articles which were submitted and are here for you today.  Enjoy!

Fighting Fatigue writes about the spirit of the holiday.  "One thing that's helped me deal with being chronically ill is being able to look at the bright side of the situation and find things that I'm still thankful for, even when life looks not-so-great sometimes."  And she challenges us to keep our own gratitude journal.

CRPS/RSD A Better Life shares an inspiring video of Alissa, a young girl with CRPS.  She's had a remarkable recovery, and supportive family, friends, and dedicated therapists who guided her along the way.

Migraine Chick writes Thank Heaven for Little Things about facing the holidays with chronic pain, and finding there are still things to be thankful for, even if they're the little things that are only important to you.

Somebody Heal Me writes about a change in perspective in her post, Being Thankful for 'Bad' Luck.  "I've learned that everything is exactly as it should be.  I'm so thankful for this gift.  Things in my life may not always be fair or desirable.  But we never know whether something is good luck or bad luck because we don't (we can't) see the whole picture.  And once you let go of the desire to label things that happen in your life, there's such freedom and the potential for great happiness."

Laurie at A Chronic Dose shares that while there will always be sickness and unexpected complications, this is a time to ignore what isn't working right and what we can't do or can't have.  Instead, focus on everything that is going our way.  Her post is Giving Thanks Recap (Straw Included).

Lisa at Chronic Illness & Pain Support with Lisa Copen writes in Counting the Blessings Hidden in Illness that finding ways to be thankful can be difficult when one lives with chronic illness.  "But if we step back and notice all the little things that happen in our lives - when we were blessed instead of given more stress - it's easy to see just how thankful we can be!"

Matthias at The Neurotopian writes a post of thanks to all scientists who have the courage to speak out under difficult circumstances and made life better for all of us.  And he shares a video of one of his favorite scientists, V. S. Ramachandran, "a brilliant scientist who's done more to help cure chronic pain than anyone else on the planet."

Keep Working, Girlfriend asks, Do you want to hear Happy Thanksgiving?  Responding to holiday good cheer can be difficult when you live with chronic pain.  Here are some ways to handle these situations.

Psychology of Pain shares a post about a man who found a cure for his pain… after a long ordeal.  Lee Nelson is a business executive who suddenly developed a very severe, intractable headache.  After years of dogged persistence, he eventually found a physician who identified the source of the pain and another whose surgical intervention was able to eliminate it.  Nelson and his wife have much to be thankful about and credit their own intellectual curiosity, motivation, and financial resources, and the diagnostic and surgical skills of some physicians (while criticizing the inaction of others).

Counting Sheep, written by a nurse anesthetist, recounts a night she spent covering an obstetrics service.  "It's about two women in pain; it's about interventions; and it's about what is fair."

Sufferer of RSD shares a way to express your thankfulness and to support someone who contributes everyday to pain organizations.  Alecia Grafton, a woman with CRPS, will donate 5% of all Christmas sales from her gift basket business, Heart Filled Baskets, to  Sufferer of RSD writes "I commend her for being able to take a gift that she has and use it to support RSD/CRPS."

Monday, November 26, 2007

What's wrong with homeopathy, by Ben Goldacre | Science | The Guardian

Time after time, properly conducted scientific studies have proved that homeopathic remedies work no better than simple placebos. So why do so many sensible people swear by them? And why do homeopaths believe they are victims of a smear campaign? Ben Goldacre follows a trail of fudged statistics, bogus surveys and widespread self-deception.

Phantom Limb Pain May Be Reduced By Simple Mirror Treatment

Phantom Limb Pain May Be Reduced By Simple Mirror Treatment

ScienceDaily (Nov. 24, 2007) — Phantom limb pain occurs in at least 90% of limb amputees according to the research. Jack W. Tsao, M.D., D.Phil., assistant professor, Department of Neurology at the Uniformed Services University of the Health Sciences (USU) conducted a sham-controlled trial using mirror and imagery therapy in patients who have had a foot or leg amputated.

Health Sciences (USU) conducted a sham-controlled trial using mirror and imagery therapy in patients who have had a foot or leg amputated.

Twenty-two patients at Walter Reed Army Medical Center in Washington, D.C. were assigned to one of three groups: one that viewed a reflective image of themselves in a mirror (mirror group); on that viewed a covered mirror; and one that was trained in mental visualization.

Eighteen patients completed the study with six in each group, and after one month of treatment 100% of the members in the mirror group reported less phantom pain, while only 17% reported a pain decrease and 50% reported worsening pain in the covered mirror group, and 67% reported worsening pain in the mental visualization group.

The study found that mirror therapy reduced phantom limb pain in patients who had undergone amputation of the lower limbs. Such pain was not reduced by either covered mirror or mental visualization treatments. These results suggest that mirror therapy may be helpful in alleviating phantom pain in lower limbs.

The study, titled “Mirror Therapy for Phantom Limb Pain,” was published in the November 22 edition of the New England Journal of Medicine.

Tuesday, November 20, 2007

A Doctors Disdain for Medical Googlers - New York Times Blog

Can a patient ever show up at the doctor's office with too much information?

A doctor's essay about medical "Googlers" — patients who research their symptoms, illness and doctors on the Web before seeking treatment — suggests they can. The report, which appeared in Time magazine, was written by Dr. Scott Haig, an assistant clinical professor of orthopedic surgery at Columbia University College of Physicians and Surgeons. He begins with a description of a patient he calls Susan, who seems to be clicking on a keyboard as she speaks to him on the phone. "I knew she was Googling me,'' he writes.

Dr. Haig's disdain for her information-seeking ways becomes quickly evident. He describes the woman's child, whom she brings to the office, as "a little monster'' and notes that the woman soon "launched into me with a barrage of excruciatingly well-informed questions.'' Every doctor knows patients like this, he writes, calling them "brainsuckers.''

Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.

The problem, Dr. Haig notes, is that patients can have too much information and often don't have the expertise to make sense of it. "There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore,'' Dr. Haig writes.

Dr. Haig's essay, however, has riled patient advocates, who believe patients need to arm themselves with information and take charge of their own medical care. Mary Shomon, who runs a popular thyroid disease blog on, recently highlighted the essay on her site, generating angry responses from readers. Ms. Shomon said she thinks many physicians like Dr. Haig are threatened by patients who use Google and other Internet resources to research their own health questions.

"By condemning Googlers, he made it clear that he's threatened by empowered, educated and assertive patients who do their own research,'' said Ms. Shomon. "He can't handle a patient who talks and doesn't just listen. Good patients…are seen and not heard, right?''

Dr. Haig concludes his essay by confessing that he decided not to treat the woman, whom he described as "the queen of all Googlers.''

I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help.

A Professors Farewell Sparks a Media Frenzy - New York Times Blog

A Professor's Farewell Sparks a Media Frenzy

In September Randy Pausch, a computer science professor at Carnegie Mellon University, gave his last lecture, telling the audience that he would soon die of pancreatic cancer. But those may not be his last public words after all.

After delivering the talk, Dr. Pausch had planned to enjoy his last days with his family. Instead, Wall Street Journal reporter Jeff Zaslow wrote a column about the unusual lecture, which he described as a "riveting and rollicking journey through the lessons" of Dr. Pausch's life, and the professor became a media sensation.

Dr. Pausch had spoken of his belief that people ultimately will impress you if you wait long enough and his view that kids should be allowed to draw on their bedroom walls. A video of the talk quickly spread over the Internet: the lecture was translated into German, even Mandarin. Dr. Pausch was asked to appear on "Oprah" and "Good Morning America." (I also wrote about Dr. Pausch on this blog.)

Apparently publishers are convinced the public wants to hear more. Today, the New York Post reports that in a frenzy for rights to a book based on Dr. Pausch's lecture, co-authored by Mr. Zaslow, bidding has reached nearly $7 million. The proposed book reportedly will tell the stories behind the wisdom Dr. Pausch dispensed that day.

To understand the fuss over one professor's final lecture, check out the talk for yourself. Here's the original Wall Street Journal article, which includes a video excerpt, as well as a follow-up story written by Mr. Zaslow. If you have time, watch Dr. Pausch's inspiring hour-long lecture in its entirety. You can download the video or find a full transcript on his home page.

Chronic Pain - Treatment - Health News - New York Times

November 20, 2007

Many Treatments Can Ease Chronic Pain

There is one undeniable fact about chronic pain: More often than not, it is untreated or undertreated. In a survey last year by the American Pain Society, only 55 percent of all patients with noncancer-related pain and fewer than 40 percent with severe pain said their pain was under control.

But it does not have to be this way. There are myriad treatments — drugs, devices and alternative techniques — that can greatly ease persistent pain, if not eliminate it.

Chronic pain is second only to respiratory infections as a reason patients seek medical care. Yet because physicians often do not take a patient's pain seriously or treat it adequately, nearly half of chronic-pain patients have changed doctors at least once, and more than a quarter have changed doctors at least three times.

In an ideal world, every such patient would be treated by a pain specialist familiar with the techniques for alleviating pain. But "very few patients with chronic disabling pain have access to a pain specialist," a team of experts wrote in a supplement to Practical Pain Management in September.

As a result, most patients have to rely on primary care physicians for pain treatment, obliging them to learn as much as they can about treatment approaches and to persist in their search for relief.


Most chronic pain patients end up taking a cocktail of pills that complement one another. These are three categories of drugs useful for treating chronic pain:

¶If the pain is not severe, nonsteroidal anti-inflammatory drugs, Nsaids for short, are often tried first. Some, like ibuprofen and naproxen, are sold over the counter. Others, like diclofenac (Voltaren) and celecoxib (Celebrex), are available by prescription. All have risks, especially to the heart and gastrointestinal tract, and may be inappropriate for those prone to a heart attack, stroke or ulcers. Nsaids must not be combined with one another or any aspirinlike drug, but they can be used safely with acetaminophen (Tylenol).

¶Several classes of drugs originally marketed for other uses are now part of the pain control armamentarium — antidepressants, especially the S.N.R.I.'s like venlafaxine (Effexor) and duloxetine (Cymbalta); antiepileptics like gabapentin (Neurontin) and pregabalin (Lyrica); and muscle relaxants like baclofen (Lioresal) and dantrolene sodium (Dantrium). These are often used in combination with specific pain-relieving drugs.

¶By far the most important class of drugs for moderate to severe chronic pain are the opioids: morphine and morphinelike drugs. Patients often reject them for fear of becoming addicted, a rare event when they are used to treat pain. Doctors often avoid prescribing them for fear of addicting patients, being duped by drug abusers or being raided by the Justice Department. Pain societies have established clear-cut guidelines to help doctors avoid such risks, including ways to identify patients who could become addicted.

Many patients and physicians do not know the difference between physical dependence on a drug (withdrawal symptoms result if the drug is abruptly stopped) and addiction (loss of control over drug use, cravings and continued use despite harm). As with other medications, like steroids and antidepressants, patients have to be gradually weaned from opioids to avoid withdrawal symptoms.

For patients with chronic, continuous pain, using a slowly released opioid like oxycodone (Oxycontin), morphine or fentanyl (administered through a skin patch or lozenge on a stick) is preferred. These drugs minimize or eliminate the hills and valleys of pain and reduce the medication patients need.

The usual side effects — sedation, nausea, confusion — soon disappear except for constipation, which can be treated.

Pain specialists also recommend that patients taking slow-release opioids have on hand a fast-acting one like Percocet (oxycodone with acetaminophen) to treat breakthrough pain.

Methadone, a synthetic opioid, is another option for managing chronic pain, especially neuropathic pain, but it has to be taken several times a day. It is metabolized in the liver, along with other drugs that can affect blood levels of methadone.

Other Remedies

Some patients in chronic pain use a technique called TENS, for transcutaneous electrical nerve stimulation, in which pulses of low-intensity electric current are applied to the skin. The theory is that the pulses transmit signals to the brain that compete with the pain signals. Unlike drugs, TENS has no side effects or interaction with drugs, and it can be used at home.

Acupuncture, another increasingly popular treatment for persistent as well as intermittent pain, is thought to work by increasing the release of endorphins, chemicals that block pain signals from reaching the brain. It may be effective in relieving headaches, facial and low back pain, and pain caused by shingles, arthritis and spastic colon.

Guided imagery, meditation, relaxation therapy and hypnosis or hypnotherapy are often useful adjuncts to pain treatment, because they can reduce stress and take one's mind off the pain. Likewise, cognitive behavioral ("talk") therapy can help patients think and behave differently with respect to their pain. Other options include massage and hydrotherapy, the use of hot or cold water to reduce inflammation and promote healing.

Many chronic pain patients can benefit from physical therapy and exercises to strengthen weak supporting muscles and relax tight joints (which for the last two years has helped me control sciatic pain), or occupational therapy to learn new ways of moving, sitting and lying down to reduce irritation of or dependence on painful body parts.

Finally, a mental adjustment may be necessary to improve the quality of life of chronic pain patients, who have to accept that they may always have some degree of pain. Chronic pain tends not to go away, and changes may have to be made both at work and at play. The goals should be to reduce pain to an acceptable level and to learn how not to make it worse.

For Further Information

Here are some groups that can provide information on managing chronic pain:

AMERICAN CHRONIC PAIN ASSOCIATION E-mail:; Web site: P.O. Box 850, Rocklin, Calif., 95677-0850; (916) 632-0922 or (800) 533-3231.

AMERICAN PAIN FOUNDATION; 201 North Charles Street, Suite 710, Baltimore, Md., 21201-4111; (888) 615-7246.

NATIONAL FOUNDATION FOR THE TREATMENT OF PAIN; P.O. Box 70045, Houston, Tex., 77270; (713) 862-9332.

This is the third of three columns. Previous columns covered the causes of chronic pain and the ways that family can help.

Monday, November 19, 2007

Brain differences seen in migraine sufferers - More health news-

Brain differences seen in migraine sufferers

Unclear whether the differences cause the pain or vice versa

WASHINGTON - People who get migraines have structural differences in their brains notably in the cortex area that processes pain and other sensory information from the body, scientists said on Monday.

The researchers, whose findings were published in the journal Neurology, said it is unclear whether these brain differences actually cause migraines or are themselves caused by these severe, recurrent headaches.

The researchers performed brain scans on 24 people who had a long history of frequent migraines — about four per month for 20 years — and 12 people who did not get migraines.

The somatosensory cortex — the area of the brain that detects sensations like pain, touch and temperature in various parts of the body — was 21 percent thicker in the people who got migraines compared to those who did not.

The biggest difference was in the part of the cortex responsible for processing sensory information from the head and face, Dr. Nouchine Hadjikhani of Massachusetts General Hospital, who led the study, said in a telephone interview.

Hadjikhani said the study illustrated the seriousness of the migraine. "It has to be taken seriously because it can induce changes in your brain," she said.

Migraines are a type of painful headache commonly accompanied by nausea, vomiting and heightened sensitivity to light and sound. Women are three times more likely than men to experience these headaches. Many people who get them have a family history of migraines.

"The more we understand about the pathophysiology of migraine, the better we will be able to design drugs that work. At the moment, there is no drug for prevention that works well," Hadjikhani said.

Dr. David Dodick, a professor of neurology at the Mayo Clinic who was not involved in the study, said the study shows that migraines are a brain disorder. "And it shows that migraine has some durable, long-lasting morphological or structural changes in the brain over time," Dodick said.

Dodick said he would be interested to know whether people who get migraines less frequently have the same brain changes.

Hadjikhani said one possibility is that repeated, long-term over stimulation of sensory fields in the cortex may cause it to become thicker over time. Another possibility is that people predisposed to migraines already have this thicker cortex, Hadjikhani said.

According to the U.S. National Institutes of Health, researchers suspect migraines are caused by inherited abnormalities in genes that control certain cells in the brain. For many years, scientists had thought migraines were linked to the dilation and constriction of blood vessels in the head.

Dr. Seymour Diamond, executive chairman of the National Headache Foundation and head of the Diamond Headache Clinic in Chicago, said in an interview the findings further confirm that migraines are a neurological disease.

Researchers have seen differences in cortex thickness in other diseases as well. It is thinner, for example, in people with multiple sclerosis, Alzheimer's disease and autism.

Sunday, November 18, 2007

Study: Brain waves reveal pain intensity

OXFORD, England, Nov. 14 (UPI) -- British researchers said they found a signal from the brain that correlates with the amount of pain a person feels, Nature reported Wednesday.

The signal could be used to refine pain relief techniques that involve using electricity to stimulate the brain, the researchers said.

While single sells have been shown to signal the presence or absence of pain, Morten Kringelbach and his team at University of Oxford identified low-frequency brain waves emanating from two regions deep within the brain when a patient is in pain. The more pain experienced, the longer the waves last, the researchers said.

"It is an objective measure that correlates with a subjective measure," Kringelbach said.

This signal could help refine deep-brain stimulations for patients of chronic pain, he said.

"We could have a stimulator that picks up this neural signature of pain and only starts sending signals at that point," Kringelbach says.

The preliminary study didn't indicate whether the duration of the waves disappeared when painkillers, anesthetics or electrical stimulation are used, said Allan Basbaum, a neuroscientist at University of California-San Francisco.

"It would be great to have a 'signature of pain,'" Basbaum said.

Morten L. Kringelbach's scientific research and papers: