Tuesday, December 23, 2008

Putting pain into perspective - Times Online

Throw out those painkillers: the secret to salving physical aches may lie in using a pair of binoculars the wrong way round, claims research performed at Oxford University.

The study, published in Current Biology, reveals how powerfully pain and even swelling can be a product of our mental attitude.

Researchers asked ten people who suffered chronic pain in one arm to move the limb around while looking at it through a pair of binoculars that were either the right or wrong way round.

When they saw their arm magnified to double its size, the patients reported that their levels of pain increased, but when they exercised the arm while watching a minimised image of it through inverted binoculars, their pain levels were cut significantly.

But it was not only their perceived pain levels that changed, says the lead researcher, G. Lorimer Moseley. Their levels of physical swelling in the affected areas were also reduced through using the backwards-binocular trick.

Moseley says he is not sure how this phenomenon works in terms of specific neurons firing, but he believes that the brain changes its protective responses according to its perception of danger levels. “If it looks bigger, it looks sorer, therefore the brain acts to protect it,” he explains.

Moseley hopes that the optical-trick discovery will lead to a practical method for lowering pain and trauma levels in hospitals.

In effect, the binocular trick offers a much simpler and cheaper version of a pain-lowering brain-scan method pioneered by American researchers. Scientists at Omneuron, a California-based company, are using a functional magnetic resonance imaging (fMRI) machine to treat chronic pain. Patients are placed in the scanner and asked to watch a computer-generated flame projected on the screen of virtual-reality goggles. The flame's intensity reflects the neural activity of regions of the brain involved in the perception of pain.

By concentrating on a variety of mental techniques - such as imagining that a painful area is being flooded with soothing chemicals or marching soldiers - most people can make the flame wane. As the image of the flame wanes, the patient starts to feel less pain.

A 2005 study of eight patients with recalcitrant pain felt their discomfort reduced by as much as 64 per cent by using Omneuron's technology. Christopher deCharms, the chief executive of Omneuron, says, “We believe that people will use real-time fMRI feedback to hone cognitive strategies that will increase activation of brain regions.”

He adds that, with practice and repetition, this could lead to “long-term changes in the brain”.

Alternatively, of course, pain patients could simply try playing around with an old pair of binoculars.


Wednesday, December 10, 2008

The Evidence Gap - The Pain May Be Real, but the Scan Is Deceiving - NYTimes.com

Cheryl Weinstein's left knee bothered her for years, but when it started clicking and hurting when she straightened it, she told her internist that something was definitely wrong.

It was the start of her medical odyssey, a journey that led her to specialists, physical therapy, Internet searches and, finally, an M.R.I. scan that showed a torn cartilage and convinced her that her only hope for relief was to have surgery to repair it. But in fact, fixing the torn cartilage that was picked up on the scan was not going to solve her problem, which, eventually, she found was caused by arthritis.

Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It's an issue particularly for the millions of people who go to doctors' offices in pain.

The scans are expensive — Medicare and its beneficiaries pay about $750 to $950 for an M.R.I. scan of a knee or back, for example. Many doctors own their own scanners, which can provide an incentive to offer scans to their patients.

And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain.

But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal.

"A patient comes in because he's in pain," said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. "We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations."

Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery.

More ...


Wednesday, December 03, 2008

Help My Hurt

Help My Hurt is blog dedicated to the topic of pain, prevention of pain, and pain management written by a nurse turned writer.


Vulvodynia: Dismissed and undiagnosed - globeandmail.com

Sufferers visit gynecologists, urologists and naturopaths in search of relief - only to be told it's 'all in their heads.' But chronic vulvar pain is real, medical researchers say, and it may affect one in six women

Three years ago, Regina Netto felt as if her vulva was on fire, "like somebody had lit up a flame down there." It was so bad that most days the 38-year-old from Laval, Que., could barely walk. And sex? Forget about it.

Her doctor thought she had a urinary tract infection - but treatment for that only worsened her pain. Blood and urine tests for a UTI came up negative, and then a cystoscopy (examination of her bladder with a small camera) showed nothing.

Thinking she had interstitial cystitis (a chronic bladder disease), a urologist prescribed Ms. Netto medication - but that didn't work either. Nor did visits to an acupuncturist, naturopath, osteopath or physiotherapist. She saw eight different gynecologists and urologists in search of relief.

Finally, she says, "A family doctor and a gynecologist told me that there was nothing wrong with me and that I needed to see a shrink."

Ms. Netto had a real condition, called vulvodynia, meaning chronic vulvar pain. But there is no test for it, and while there is some faint visible redness in some women, on the surface most women with vulvodynia look completely normal. This makes the condition difficult to diagnose and leaves sufferers prone to hasty dismissal by their physicians. Most GPs - and many gynecologists - are not even aware of its existence.

But research is now uncovering the concrete, physical markers of vulvodynia, giving therapists the tools they need to develop effective treatments.

In 2006, the American College of Obstetricians and Gynecologists and the American Academy of Family Physicians felt the need to print an educational piece on the condition in their monthly newsletter, sent to 150,000 physicians, with information on how to diagnose and treat it.

"Vulvodynia, like many conditions, has historically suffered from a lack of understanding," says Lori Heim, a director of the AAFP. "But it is real - it is not a psychological condition. And now more is known about it, its extent, and how to diagnose and treat it, so we decided to provide our members with education because the information has evolved."

"One of the difficulties is that there is no test for vulvodynia," says Marc Steben, a family physician and clinical researcher of vulvodynia in Montreal. "The diagnosis is one of exclusion." In other words, when you can't peg the problem as anything else - say, a yeast imbalance, a bladder infection or interstitial cystitis - then it could be vulvodynia.

If all the tests turn up negative, says Alan Gerulath, a gynecologist at St. Michael's Hospital in Toronto, properly diagnosing vulvodynia is "based on symptoms, primarily burning - but not itching - discomfort."

More than a single ailment

To complicate matters, vulvodynia is not just one simple ailment, but an umbrella term for a number of conditions - which may be why the National Institutes of Health in the United States says the condition affects an estimated one in six women at some point in their lives.

One group of women, with what is dubbed "vulvar vestibulitis syndrome," suffer pain just at the opening of their vaginas, usually only with physical contact. Vestibulitis tends to strike early in life, usually before 25, and because the pain is localized it is easier to diagnose, Dr. Gerulath says.

More difficult to pinpoint is "generalized vulvodynia," which causes burning pain in the entire vulva without any contact, sometimes 24 hours a day. This commonly starts between the ages of 35 and 44.

Research has shown that all women with vulvodynia have a higher density of nerve endings in their vulvas. And scientists have documented genetic differences in women with vulvodynia that cause them to respond abnormally to infection and injury.

For many women, an injury - say a chronic yeast infection or childbirth - sparks an immune- and nervous-system response that fails to turn off. The initial problem has disappeared, but their nerves continue to fire pain signals to their brains.

Drugs that control levels of hormones, neurotransmitters and other biochemical messengers are frequently prescribed, such as estrogen creams, anti-epileptics such as gabapentin, and tricyclic antidepressants such as amitriptyline (in doses too low to have an antidepressant effect, but enough to dampen the nerve signals).

Allan Gordon of the Wasser Pain Management Centre in Toronto finds that about one-third of his vulvodynia patients respond to medication. But "there have been very few good, appropriate clinical trials - a lot of the ideas are based on anecdotal evidence about what seems to work," he says.

In another possible clue to the brain's role in vulvodynia, Canadian researchers published a study last month in the scientific journal Pain that demonstrated evidence of altered brain structure in women with provoked vestibulodynia (a newer and more accurate term for vestibulitis). They found that 14 women who had suffered from PVD had more grey matter in the regions of their brains associated with pain and stress.

What this actually means is "purely speculative at this point," says Petra Schweinhardt of McGill University, one of the study's co-authors. It could mean that women who have suffered from PVD experienced changes in their brains as a result of their pain, or it could mean they were born this way. "It could be one or the other, but our speculation is that the increased grey matter might represent an inflammatory response by cells in the brain," Dr. Schweinhardt says.

Surgical option

Because so little of what is known is conclusive, finding the right solution for each patient is a matter of trial and error, involving a mixture of physiotherapy, diets, drugs and therapies such as acupuncture. As a last resort, some women turn to surgery and have small chunks of their vulvas removed - a procedure recommended only for women with pain in small, specific spots.

But Howard Glazer, a neurophysiological psychologist from Toronto who operates a private clinic for urogenital pain in New York (and who co-authored a paper in the journal Obstetrics and Gynecology on treatment options), says he has seen a lot of women still in pain after surgery.

He is equally disapproving of drugs. He says the best option is to help the body to heal itself by increasing blood flow to the vulva, and therefore the delivery of oxygen and the body's own repairing mechanisms. He does this by first mapping the physiology of his patients with a sensitive probe, then teaching them how and where to exercise their vaginal muscles to increase blood flow appropriately.

Controversial therapy

More controversially, he also tells his patients to get back in touch with their sexuality, pronto, and have "a minimum of three to five orgasms a week," since arousal also increases blood flow.

"[Dr.] Glazer's idea might be a little overstated - I wouldn't want to put all the onus on the patient - but this could be good as a secondary therapy," Dr. Gerulath says. "Anything that relieves muscle spasms can help."

"I wouldn't recommend intercourse if it is very painful - that would be counterproductive - but I do think that engaging in sexual activity can be helpful, by exercising and helping to improve blood flow," Dr. Gordon says. "It is still speculative at this point if it will 'heal' them, but it is possible. There are a number of anecdotal reports that suggest sexual activity, masturbation and orgasm can be helpful."

Naturally, many women suffering from the condition have little interest in sex. But Dr. Glazer argues that anxiety weakens the immune system and exacerbates the condition, so he advises his patients to overcome their fear with counselling and patience.

Although Dr. Gerulath feels the best treatments could lie in future drugs that help the nervous system, he acknowledges that vulvodynia is "a problem with the way the brain receives and interprets pain signals. Certainly there are a lot of examples of mind-body interactions, and absolutely you can influence your own symptoms," he says. "But as to what techniques work, that is a whole other can of worms."

To think of vulvodynia as "psychological" just because it has a psychological component is a gross oversimplification, Dr. Glazer says. "This does not for a second mean that vulvodynia is 'all in their heads' - that is not how the body works. The simplistic thinking that something is either 'real' or 'in your head' should have died out in the 1950s."

Lisa Hunt, who suffers from vulvodynia, spent five years looking for a doctor in Calgary who could help her. After a battery of tests by a number of doctors, she too was given dismissive treatment by her GP.

"He told me flat out that this is not a 'medically recognized condition' and that it was all in my head," the 28-year-old says.

With Dr. Gordon at the Wasser clinic, she says she feels lucky because she is "finally seeing a doctor who knows more about this than I do."