Sunday, April 05, 2009

Medicine is gaining on pain | Jerusalem Post (click here)

Everyone knows what pain is - from giving birth, a stubbed toe, an
infected tooth, a burn, surgery or a fall - and the physiological
mechanism is well understood. But chronic pain, from which nearly 20
percent of the population suffer - migraines, rheumatic disease,
cancer, neuropathy, "phantom limb" syndrome, spinal problems and
others - is considered a fully fledged "illness" in addition to the
pathologies that cause it.

Pain is one of the most persistent health problems faced by humanity.
Although chronic pain itself is not life-threatening, it can lead to
depression and suicide.

Unfortunately, the mechanism involved in chronic pain is still not
completely understood and thus it's not preventible or curable, but
neuroscientists like Hebrew University Prof. Marshal Devor continue
to make progress in trying to find answers. He has come to one big
conclusion - that specific genes determine why two patients with
exactly the same stage of the same disease may experience different
amounts of pain. This variability from one person to the next is a
major puzzle.

Prof. Marshall Devor, 60, who was born in Toronto and studied at
Princeton and MIT, came on aliya 30 years ago. Today he works in the
department of cell and animal biology at HU's Institute of Life
Sciences, and his lab has published extensively on pain,
neurophysiology, neuroanatomy, genetics and animal behavior.

THE VARIABILITY in the sensation of acute pain, says Devor, is clear
when a slap in the face that provokes sobs in one person is laughed
off by another. Every individual has a different pain threshold, and
variability in expression has also been attributed to cultural and
psychosocial factors such as personality and upbringing. Women in one
country may scream in delivery rooms while those in another are
silent. In some countries, he notes, people "don't hesitate to
express their pain, while in others, children are taught to be
stoical. There are also big differences between men and women, girls
and boys... Is it possible that the socialization of boys and girls
actually alters the amount of pain experienced, and not just how pain
is expressed?"

Devor stresses that pain cannot be shared. "Pain is inherently a
private, first-person sensory and emotional experience. It is felt by
the person; even using delicate instruments, a doctor cannot know
exactly how intense is the suffering of a victim; he can only observe
outward behavior and language." However, pain can be measured
subjectively by sufferers on a scale of 0 to 10. Children can
describe the amount of pain they feel using a graphic scale of faces.
Animals can feel pain, says Devor, and can be judged by their
reactions such as pulling a paw away.

Advances in non-invasive brain imaging such as functional magnetic
resonance imaging (fMRI) or positron emission tomography (PET) may
soon make it possible to know objectively whether someone is faking
or exaggerating his pain; the amount of neural activity, he says,
rises and falls in certain parts of the brain to reflect the amount
of pain, but the amount of pain felt can be changed by hypnosis, pain-
killing drugs and even anticipation. One can also observe signals
indicating that a loved one of the person you are testing is in pain.
"Just knowing that a loved one is suffering affects your own brain,
and you can see such empathy in monkeys and even mice."

Pain, he adds, "is both friend and foe. Acute pain is for the most
part a friend, as it warns of a problem; but if a part of torture,
such pain is of course a foe." Chronic pain is a foe as well, and
while it is defined as suffering that lasts at least six months, the
average is at least four years.

Pain "resides at the interface of body and mind; only people who are
conscious can feel pain." It has been defined by pain experts as "an
unpleasant sensory and emotional experience associated with actual or
potential tissues damage, or described in terms of such damage."

Neurons in the spine, explains Devor, have long axons. A stimulus
generates electrical impulses, and the signal goes into various parts
of the cerebral cortex and other brain regions called the pain
matrix. The stimulus affects specific patches of brain cells.
Scientists don't know how pain is experienced in the brain. It is
initiated by physical stimuli translated into electrical signals, the
neuroscientist continues, "but if you stimulate nerve fibers
electrically along the path, a person will say he feels a sensation,
not in the nerve but in his hand, for example. If a nerve is injured,
or you have a viral infection or inflammation, the injury site
becomes an abnormal source of electrical impulses. They run to the
brain and are perceived there."

Phantom limb pain is very puzzling. If a hand or arm has been
amputated or lost - as happened to Admiral Lord Nelson (who died in
the 1805 Battle of Trafalgar) - one can still feel pain in the
missing part. The brain sends signals down the spinal cord, causing
the victim to feel pain without the signal reaching the limb.

ONE CAN also be seriously injured without feeling pain: Devor
describes a drawing from the Battle of Handak, which involved a
schism between Shi'ite and Sunni Muslims. The leg of a soldier in the
battle was severed and he goes on to use his limb as a weapon, as he
feels no pain. This phenomenon has also been documented in people who
suffer severe injuries in road accidents. Animals too can suppress
pain caused by sudden events. This is called stress-induced neuralgia.

One's expectations also affect pain perception. If one goes to a non-
medical "healer" who waves his hands above your body or ties a red
string around your wrist, or to a clergyman who gives you a blessing,
these can relieve pain, Devor says. Faith and superstition can
actually relieve pain. "The belief that a red string will relieve
pain can actually relieve pain. It's called placebo analgesia, and
it's real and sometimes powerful. It could even be as effective as an
injection of morphine." This ability, he suggests, "was given to the
brain to suppress pain in times of emergency. It is endogenous,
designed to let the body fight and struggle, and lick the pains
later. It is brain circuitry of relief."

An experiment was conducted to allow Christian subjects to meditate
on either of two photos - an ordinary woman and the Virgin Mary. The
images look similar, and the subjects were either devout Catholics or
atheists. Both were then exposed to a heat stimulus. The image of
Mary had no pain-relieving effect in the non-believer group, but it
did relieve pain in the devout, recalls Devor.

He notes that for many years, pediatricians and parents were unaware
that newborn infants felt pain because they thought their nervous
systems were still undeveloped - or that they wouldn't remember it
anyway. For that reason, when painful procedures were conducted, no
analgesia was offered. But more recent studies have shown that
newborns are indeed capable of feeling pain, and not giving
anesthesia before a painful procedure is now considered a form of abuse.

"We don't know how much newborns remember pain or for how long, but
an Israeli study showed that eight-year-old boys who have been
circumcised cry much more than girls after they get childhood

IN ADDITION to socialization and other psychosocial and environmental
factors, says Devor, differences in the wiring of our individual
brains due to gene variations are responsible for how people respond
to pain.

Rare familial diseases inherited by some people but not by others
give good evidence of this, as have identical-twin studies. More
recently, scientists have been identifying specific genes that make
it more likely that one will suffer pain in response to injury or
disease, says the neuroscientist.

New knowledge of how genes affect pain could not only lead to
improved pain relief but also eliminate the stigma of being a
"crybaby" in people who say their condition is more unbearable than
that suffered by others with the same disease; the difference can be
explained by their DNA.

Not all 25,000 genes in each cell affect pain sensation, he says.
"For some genes, however, there are rare variants [mutations] or
common variants [polymorphisms] that do affect the functioning of the
proteins encoded... At present, we have no idea how many genes"
affect pain response. Some pain genes may have no effect on pain at
all except under unusual circumstances, Devor says, such as at high
altidues or if your sister-in-law made you particularly exasperated.
In this case, the genes' influence interacts with the environment.
Certain pain relievers such as opiods, he concludes, relieve pain in
one sex or another.

"The genetic revolution has only just started to affect the field of
pain science and medicine. There is well-founded optimism abut the
potential power of linkage analysis and association studies... The
payoff in terms of new therapeutic options is likely to be not too
far down the road. That is certainly good news for the one in five
prople who suffer from chronic pain."

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