Wednesday, March 26, 2008

For amputees, an unlikely painkiller: Mirrors -

For amputees, an unlikely painkiller: Mirrors

WASHINGTON (CNN) -- Army Sgt. Nick Paupore was in the lead Humvee in a convoy rolling through Kirkuk City, Iraq, when the vehicle was hit by a roadside bomb.

Paupore says it wasn't a very big explosion, more like a loud firecracker. He could feel the rush going through the vehicle, the change of pressure, smoke filling the cab. He felt a burning sensation in the back of his legs, but he wasn't in pain, and he could actually move his legs. He felt lucky. He was alive. He got out of the vehicle, intending to help the others, and passed out.

When he regained consciousness, medics were working on him. The blast had ripped out a chunk of his leg, including 6 to 8 inches of an artery, and he was bleeding out. By the time they had stanched the flow, he had less than two pints of blood left. The average person has 10 pints of blood.

Paupore was flown to Germany, where doctors fought to save his life. He survived, but they couldn't save his leg.

And he was in excruciating pain -- in the leg he no longer had.

Dr. Jack Tsao, a Navy neurologist with the Uniform Services University, was looking for ways to help soldiers like Paupore. He remembered reading in graduate school a paper by Dr. V.S. Ramachandran that talked about an unusual treatment for amputees suffering "phantom limb pain," using a simple $20 mirror.

The mirror tricks the brain into "seeing" the amputated leg, overriding mismatched nerve signals.

Here's how it works: The patient sits on a flat surface with his or her remaining leg straight out and then puts a 6-foot mirror lengthwise facing the limb. The patient moves the leg, flexing it, and watches the movement in the mirror. The reflection creates the illusion of two legs moving together.

Paupore was one of the first to give it a try. At first, he was skeptical. When approached about joining a clinical trial at Walter Reed Army Medical Center to test Tsao's theory, he declined. But sometimes his phantom pains were coming five to six times an hour and lasting up to a minute.

"I was laying in bed and it just, all of a sudden, it felt like I was getting shocked," he said. "I called the nurse, 'cause I was like, 'What's going on?' " The nurse told him, "This is probably your phantom pain.

Tsao explains it this way: "It's the sensation that the limb is still present, and phantom pain in particular is the sensation that the limb is experiencing pain of some form."

That pain is intense, and often medication brings very little relief. For Paupore, it was relentless.

"All of a sudden, it was like someone kept turning on and off the Taser, and my whole leg started twitching. ... I sat up, and I was holding on to my stump, and it just wouldn't stop. At that time, I was hooked up to the Dilaudid [a powerful narcotic], and I was pushing it. But you can push all the medicine in the world, and it won't stop it."

Paupore and 17 other amputees who joined Tsao's mirror therapy trial were randomly assigned to one of three groups. The first group used the mirror to look at their reflected image as they tried to move both legs. The second group used a covered mirror and did the same. And members of the third group were asked to visualize moving their amputated limbs.

After a month of treatment, all of the patients in the mirror group had significantly less phantom pain. In the covered mirror group, only one patient experienced a decrease in pain, and for half of those patients, the pain worsened. Sixty-seven percent of the patients visualizing their limbs got worse instead of better. The pain decreased in almost 90 percent of the patients who then switched to mirror therapy.

It worked wonders for Paupore, 32. Within five months, he was off painkillers completely. Tsao says the difference is like night and day.

"To see him walking, he's able to drive his car; he works downtown; I mean, that is incredibly gratifying!"

Phantom limb pain plagues as many as 95 percent of amputees, Tsao said.

He says even though phantom pain dates to Civil War days, no one knows what causes it. The current thinking is that it has to do with how the brain interprets signals from the pain pathways that are left after amputation.

The neurons that control leg movement are still there, but in the absence of a limb, they are not sure what they're supposed to do and begin firing randomly. Proprioception, the body's ability to sense the position of a limb, tells the body that the limb is still there, sending mismatched signals to the brain.

"The visual neurons are still intact, and they're firing off, telling the brain one thing," Tsao said. "The propriaceptive neurons are firing off, telling the brain something else. ...My thinking is that there is some sort of center in the brain that coordinates these signals. ... Somehow, this mismatched feedback is what's generating the sensation that the limb is frozen or in pain."

Since the conflicts in Afghanistan and Iraq began, more than 750 amputees have returned home from that area. Walter Reed has treated more than 550 of them. On any given day, between 100 and 125 amputees are there, working to rebuild their lives.

At Reed, mirror therapy is now offered routinely. Tsao says this treatment has the potential to benefit amputees worldwide, and the best part is, no special training is required to do it. He gives interested parties instructions over the phone or by e-mail.

And he's already taken this therapy halfway around the world to Cambodia, a country Tsao says has a large and growing amputee population because of mines left over from its civil war.

'Virtual massage' can relieve amputees' phantom limb pain - New Scientist

Amputees who experience phantom limb pain could find relief in a surprisingly simple way - by paying more attention to the people around them.

Phantom limbs occur when an amputee feels the often painful sensation of touch arising from a limb that is no longer present. Working with combat veterans, Vilayanur Ramachandran, of the Center for Brain and Cognition at the University of California, San Diego, has now discovered a potential cure.

His treatment makes use of the newly discovered properties of mirror neurons. Mirror neurons fire when a person performs an intentional action - such as waving - and also when they observe someone else performing the same action. They are thought to help us predict the intentions of others by creating a "virtual reality" simulation of the action in our minds.

"You also find cells like this for touch," says Ramachandran. "They fire when you touch yourself and when you watch someone else being touched in the same location."


This begs the question: if the same touch neurons fire when you rub your hand as when you watch somebody else rubbing their hand, why is it that we don't constantly go around "feeling" what we are watching?

Ramachandran proposed that messages from sensory cells in the hand would partially inhibit the output of mirror neurons, preventing the message from going to higher centres of the brain.

"They're telling the brain: 'I feel your touch in some abstract way but not in a literal sense'," he says. "This mechanism allows you to simultaneously empathise and recognise that someone else is being touched but not think you are being touched yourself. "

To test this theory, Ramachandran and his colleague and wife Diane Rogers-Ramachandran used a "mirror box" - a tool that creates the visual illusion of two hands for people who actually only have one. By placing an amputee's arms either side of a mirror - with the missing limb on the non-reflective side, the amputee sees the reflection of their normal hand superimposed on the location of their missing hand.

Mirror magic

Two amputees watched their normal hand being prodded, and both felt the remarkable sensation of "being prodded" in their missing hand. In another experiment, when the amputees watched a volunteer's hand being stroked, they too began to experience a stroking sensation arising from their missing limb.

The amputees "felt" the actions of others because their missing limb provided no feedback to partially inhibit their mirror neurons, no longer telling them that they were not "literally" being touched, says Ramachandran.

One subject also reported that watching a volunteer rubbing her hand caused the cramping sensation within the phantom limb to cease for 10 to 15 minutes. "If you do it often enough perhaps this pain will go away for good," suggests Ramachandran.

"If an amputee experiences pain in their missing limb, they could watch a friend or partner rub their hand to get rid of it."

Remote massage

Massaging the skin helps relieve a painful sensation by restoring blood flow and activating sensory fibres, which inhibit pain messages to the brain. By watching another person rubbing their hand, these amputees are apparently tapping into this latter mechanism, says Ramachandran.

The number of amputations as a result of conflict are increasing globally. In Iraq, for example, amputations are performed on 6% of wounded US soldiers, twice the amount as has been seen in other conflicts. But Ramachandran says there could be broader applications to the work than helping amputees.

"If performed early enough, this type of therapy may also be used to help stroke patients regain movements by watching others perform their lost actions," Ramachandran suggests.

The research has implications that go beyond the case of amputees, agrees Valeria Gazzola, at the School of Behavioural and Cognitive Neurosciences' Neuro Imaging Center at the University of Groningen, the Netherlands.

"Ramachandran has provided a very plausible answer to other problems such as why echopraxics imitate most of the actions they observe, although it will be important to see the full-length papers on the topic before relating it to other disorders."

Journal ref: Medical Hypotheses, DOI: 10.1016/j.mehy.2008.01.008

BBC NEWS | Health | Pain lingers 'long after trauma'

Pain lingers 'long after trauma'

Most patients recovering from severe injuries are still in pain a year later, researchers have found.

Scientists analysed data from more than 3,000 patients, and concluded that 62% continued to suffer 12 months after their injury.

In the Archives of Surgery journal, the University of Washington team called for more intervention to control pain as swiftly as possible.

UK patients face the same problems, said one specialist physiotherapist.

In the UK, once a trauma patient has left hospital, the responsibility for helping them usually falls to their GP and local pain management services.

A report published in 2004 suggested that the quality of chronic pain management in primary care, and the amount offered to patients, was "highly variable".

Only one in 25 of those primary care trusts which replied said that they were even trying to record how many patients they had suffering from chronic pain.

The US finding clearly sets out the burden of long-term pain on those suffering traumatic injuries.

The patients in their survey were aged between 18 and 84, who had all survived at least one year after their accident.

After 12 months, they were asked to rate their pain on a 10-point scale, and almost two-thirds said they were still in pain, often in more than one part of the body.

The average level of pain was not excruciating, but still severe - a rating of 5.5 on the scale.

Three or more painful areas were reported by 59% of those with injury-related pain.

The researchers wrote: "The presence of pain varied with age, and was more common in women and those who had untreated depression before injury.

"Pain at three months was predictive of both the presence and higher severity of pain at 12 months.

"The findings of this study suggest that interventions to decrease chronic pain in trauma patients are needed."

Striking early

They suggested that more work at the time of the injury to deal with "early pain" might be effective.

Peter Gladwell, a specialist physiotherapist with an interest in pain management, and a member of the Physiotherapy Pain Association, said that research findings were consistent with his experiences with patients.

"Chronic pain can have a devastating effect on patients, on all kinds of areas of their lives.

"It's pretty well understood now that any delay in getting specialist opinion on pain management is unhelpful, and our waiting times are nowhere near as long as they were.

"There is plenty of evidence that early, good quality, pain relief can improve the outcome for patients."

Pain Gene Therapy: Science Videos - Science News - ScienCentral

Researchers are developing a long-lasting way to relieve chronic pain with a single injection. As this ScienCentral video explains, the work so far has been done in rats, but researchers hope to one day offer it as an alternative when even strong drugs like morphine fail.

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

Welcome to March's Pain-Blog Carnival…  the best posts of this month. 

In Sickness and in Health writes an intriguing post about how a child's game helps her gain distance from pain.

Nickie's Nook shares a moving personal story of being open to psychological coping skills, despite what that admission might mean in our society. 

Read about dealing better with migraines triggered by:

Accepting our chronic illness means:

Learn how to manage the challenges to a good night's sleep that pain can bring at Healthskills.

Read about spreading the word about pain at Afflicted with RSD/CRPS.

CRPS-RSD A Better Life links to a fascinating video about a brain researcher who describes her own stroke.

And last, a great resource list I came across at Fighting Fatigue on Fibromyalgia and Chronic Fatigue Syndrome.

Tuesday, March 25, 2008

More Expensive Placebos Bring More Relief - New York Times

More Expensive Placebos Bring More Relief

In marketing as in medicine, perception can be everything. A higher price can create the impression of higher value, just as a placebo pill can reduce pain.

Now researchers have combined the two effects. A $2.50 placebo, they have found, works better one that costs 10 cents.

The finding may explain the popularity of some high-cost drugs over cheaper alternatives, the authors conclude. It may also help account for patients' reports that generic drugs are less effective than brand-name ones, though their active ingredients are identical.

The research is being published on Wednesday in The Journal of the American Medical Association.

The investigators had 82 men and women rate the pain caused by electric shocks applied to their wrist, before and after taking a pill. Half the participants had read that the pill, described as a newly approved prescription pain reliever, was regularly priced at $2.50 per dose. The other half read that it had been discounted to 10 cents. In fact, both were dummy pills.

The pills had a strong placebo effect in both groups. But 85 percent of those using the expensive pills reported significant pain relief, compared with 61 percent on the cheaper pills. The investigators corrected for each person's individual level of pain tolerance.

"It's a great finding," said Guy H. Montgomery, an associate professor of cancer prevention at the Mount Sinai School of Medicine who was not involved in the research. "Their manipulation of price affected expectancies of drug benefit, and pain is the ultimate mind-body phenomenon."

Previous studies have shown that pill size and color also affect people's perceptions of effectiveness. In one, people rated black and red capsules as "strongest" and white ones as "weakest." Other information like the country where the drugs were manufactured can also affect perceptions.

"It's all about expectations," said the lead researcher, Dan Ariely, a behavioral economist at Duke and the author of a new book, "Predictably Irrational: The Hidden Forces That Shape Our Decisions" (HarperCollins). His co-authors on the report were Rebecca Waber, Baba Shiv and Ziv Carmon.

"When you're expecting pain relief, you're secreting your own opioids," Dr. Ariely added. "And when you get it on discount, you doubt it, and your body doesn't react as well."