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."