AAN Guideline Recommends Against TENS for Chronic Low-Back Pain

 A new evidence-based review from the American Academy of Neurology concludes that transcutaneous electric nerve stimulation (TENS) is not recommended for use in treating chronic low-back pain but adds that TENS should be considered to treat diabetic neuropathy.

The report, from the academy's Therapeutics and Technology Assessment Subcommittee, was published online December 30 in Neurology. Authors on the new document are Richard M. Dubinsky, MD, MPH, from Kansas University Medical Center in Kansas City, and Janis Miyasaki, MD, MEd, from Toronto Western Hospital, Ontario, Canada.

"In the highest-quality studies of chronic low back pain, there was no benefit of TENS compared to sham or placebo TENS, leaving us to conclude that it is of no benefit, and make a recommendation that it should not be used for chronic low back pain," Dr. Dubinsky told Medscape Neurology.

In diabetic polyneuropathy, some studies showed slight benefit, he added. "We concluded it should be considered in the treatment of diabetic polyneuropathy."

Systematic Review

TENS has been used to treat neurologic and other disorders for decades, the authors write. The biologic basis of its analgesic effect is not known, but it is used is based on the gate theory of pain, they note. In this assessment, the authors carried out a systematic literature search of Medline and Cochrane Library up to April 2009, looking for controlled clinical trials in which TENS was used to treat pain associated with neurological conditions.

Acute low back pain not normally seen in neurologic conditions was not considered in this review. All but 1 of the studies excluded patients with known causes of low-back pain, such as pinched nerves, severe scoliosis, severe spondylolisthesis, or obesity.

"We only found 2 conditions that had adequate rigor in the research, and that was chronic back pain and diabetic polyneuropathy," Dr. Dubinsky said.

The studies included showed conflicting results in chronic low back pain. Two class 2 studies showed benefit, but 2 class 1 studies and another class 2 study showed no benefit. "Because the Class I studies are stronger evidence, TENS is established as ineffective for the treatment of chronic low back pain," they write.

Two class 2 studies suggested that TENS is probably effective in treating painful diabetic neuropathy. The only specific neurologic cause of chronic low-back pain in which TENS was studied was multiple sclerosis, for which TENS was not shown to be of benefit.

The document makes 2 main recommendations:

• TENS is not recommended for the treatment of chronic low-back pain because of a lack of proven efficacy (level A, 2 class 1 studies).
• TENS should be considered for the treatment of painful diabetic neuropathy (level B, 2 class 2 studies).

The document also gives some guidance on the need for further research into TENS, Dr. Dubinsky noted. Among their recommendations were determining what the best paradigm is, in terms of current, pulse-width, and frequency, and then using it in patients who are naive to TENS so that they will be truly blinded to treatment allocation, and studying TENS in patients with well-defined neurological conditions.

Absence of Evidence

In an editorial accompanying the new document, Andreas Binder, MD, and Ralf Baron, MD, from the Division of Neurological Pain Research and Therapy in the Department of Neurology at Christian-Albrechts-Universität Kiel, Germany, write that the conclusions of Dr. Dubinsky and Dr. Miyasaki "may heat up the discussion on the usability of TENS and may be viewed as supporting the critics who questioned the value of TENS in pain therapy.

"However," they add, "absence of evidence is not evidence of absence. The clinical impact of meta-analyses is always limited by the quantity and quality of conducted trials."

TENS has had a long-standing role in pain management, is easy to handle, has a favorable benefit-to-risk ratio, and can be discontinued easily if it is not efficacious — all "desirable properties when treating pain," they write. The new document calls for further trials and even provides "clearcut recommendations for their conduction," they note.

"This updated evidence-based review is valuable in providing the limits of our evidence base," Dr. Binder and Dr. Baron conclude. "Nevertheless, it is not unreasonable to take a practical position that, in spite of the relatively weak scientific and clinical evidence, TENS still represents a valuable therapeutic alternative in neurologic pain disorders.

"Taking the favorable benefit-risk ratio when compared with other pain relieving methods into account, TENS remains a valuable part in the armamentarium of pain therapy."

http://www.medscape.com/viewarticle/714493

Pain Pathways magazine

Welcome to PainPathways, a quarterly magazine for acute, chronic and cancer pain management. PainPathways is the ultimate resource for patients, caregivers and physicians seeking current research and therapies and is available in doctors' offices, Barnes & Noble and B. Dalton bookstores nationwide. PainPathways may also be purchased online.

This fall we feature Bob Greene, best known as Oprah Winfrey's trainer and frequent guest on "The Dr. Oz Show."  As he discusses in his feature, Mr. Green is passionate about moving and living a healthy, balanced life. Read about his "circle of life" exercise and how it can help set priorities and build meaningful relationships.  

We are also pleased to feature Andrew Levy and his new book, A Brain Wider Than the Sky: A Migraine Diary (Simon & Schuster, 2009). Levy explores his personal experience with migraines and how journaling about one's pain can help one learn to manage it. Also in this issue, we offer Well Winters, tips on staying healty during the cold months; Erythromelalgia, a rare but painful condition that is requently misdiagnosed; presenteeism, the dilema of coming to work even when one is in pain and new advances in organic pain relief.  If you know a young athlete, you'll want to read our article on how youth athletics can lead to adult chronic pain.

This winter's physician spotlight focuses on Craig T. Hartrick, MD whose current research is on chronic post-surgical pain.  Dr. Hartrick is also the editor-in-cheif of Pain Practice, a journal for pain physicians. 

http://www.painpathways.org/

How To Cope With Pain Blog

Recent Blog Entries:

• Gifts For You – Make A Donation To Any Pain Organization
• Do Medical Students Retain Information About Pain?
• Do Your Values Help You Accept Pain?
• Gifts For You – Sign Up To Get How to Cope with Pain Delivered To You
• A Magazine For Patients With Pain

http://www.howtocopewithpain.org/blog/

YouTube - IFFGD's Channel

The International Foundation for Functional Gastrointestinal Disorders (IFFGD) is a nonprofit education and research organization dedicated to informing, assisting and supporting people affected by digestive disorders.

The largest and most active organization of its kind, IFFGD has been working with patients, families, physicians, practitioners, researchers, employers, regulators and others to broaden understanding about the disorders we address.

We work with an international group of experts from multiple disciplines who serve on our medical advisory board. We provide a link between clinical research and patient care. Working together, we help ensure that clinical advancements result in improvements in the quality of life of those affected.

We are working to spread the word about the diagnosis, treatment, and management of gastrointestinal disorders, including: 

• Abdominal Pain

• Bloating

• Chronic Constipation

• Cyclic Vomiting Syndrome

• Chronic Diarrhea

• Chronic Intestinal Pseudo-obstruction (CIP)

• Dyspepsia

• Esophageal Disorders and Gastroesophageal Reflux Disease (GERD)

• Gastroduodenal Disorders

• Gastroparesis

• Hirschsprung's Disease

• Incontinence

• Irritable Bowel Syndrome (IBS)

• Pelvic Floor Pain

IFFGD offers a community of support for people affected by functional GI and motility disorders. We are a resource for anyone seeking increased knowledge about these disorders. We invite you to become a part of our worldwide community of support.

http://www.youtube.com/user/IFFGD

Website:

http://www.iffgd.org/

Why pain sometimes lingers : Nature News

A once-mysterious neural pathway may have a crucial role in making injured areas overly sensitive to touch, a study in mice suggests.

When a person has any kind of injury — a broken shin, for example, or a sunburn — the pain system becomes hypersensitized, firing up in response to normally painless sensations induced by, for instance, walking or a gentle massage. Normally, this tenderness protects the vulnerable tissue as it heals. But occasionally the pain can overstay its usefulness, becoming chronic in conditions such as arthritis.

Now, neuroscientists Robert Edwards and Allan Basbaum from the University of California, San Francisco, and their colleagues have found that a small subset of nerve fibres, the function of which remained a puzzle since their discovery decades ago¹, could be routing innocuous touch sensations to the pain pathway when there's an injury.

"Surprise would be an understatement," says Basbaum, referring to the findings. "No one knew anything about what these fibres were doing."

The team's findings are published by Nature².

The researchers found that the fibres, called unmyelinated low-threshold mechanoreceptors (C-LTMRs), are easily stimulated, unlike classic pain fibres, which respond only when the sensation is intense. But C-LTMRs aren't usually used to detect light touch — this falls to another another major group of sensory neurons — so their role was unclear. The small population of cells have remained enigmatic because they have been difficult to target specifically.

The authors cleared that hurdle when they discovered

More ...

http://www.nature.com/news/2009/091115/full/news.2009.1084.html

Scientists Discover Skin Also Senses Via Blood Vessels And Sweat Glands And Not Just Nerves

An international team of scientists has discovered that the human body has an entirely unique and separate sensory system that is largely imperceptible in most people and is based on blood vessels and sweat glands and not on nerves. They found that people lacking known nerve receptors can still touch and feel, and the discovery of how this is possible may help us understand unexplained pain such as fibromyalgia.

An article on the discovery appears in the the the December 15 issue of the journal PAIN, and describes the work of researchers at Albany Medical College, New York, USA, the University of Liverpool and Cambridge University in the UK, and other research centres.

Senior author Dr Frank Rice, a Neuroscience Professor at Albany Medical College (AMC) told the media that the discovery was:

"Almost like hearing the subtle sound of a single instrument in the midst of a symphony."

"It is only when we shift focus away from the nerve endings associated with normal skin sensation that we can appreciate the sensation hidden in the background," added Rice, who is a leading authority on the nerve supply to the skin.

Rice and colleagues got the opportunity to discover this hidden sensory system when lead author Dr David Bowsher, Honorary Senior Research Fellow at the University of Liverpool's Pain Research Institute, diagnosed two unrelated adult patients with a previously unknown abnormality consisting of "congenital absence of pain with hyperhidrosis (CAPH)".

The condition meant that both patients were born with very little ability to feel pain. The condition is rare, and people who have it also have excessively dry skin, often have severe mental handicaps and are prone to harming themselves by accident.

Bowsher explained that:

"Although they had a few accidents over their lifetimes, what made these two patients unique was that they led normal lives. Excessive sweating brought them to the clinic, where we discovered their severe lack of pain sensation."

He said he and his colleagues became more curious when they did tests with sensitive instruments and found that all the skin sensation on both the patients was severely impaired, including their ability to sense temperature and mechanical contact. 

The authors wrote that "sural nerve biopsy showed that all types of myelinated and unmyelinated fibers were severely reduced".

"But, for all intents and purposes, they had adequate sensation for daily living and could tell what is warm and cold, what is touching them, and what is rough and smooth," said Bowsher.

Bowsher sent skin biopsies to Rice's lab in the US, where they specialize in examining the nerve endings of skin at the multimolecular level to help analyze chronic pain linked to conditions like nerve injuries, diabetes and shingles. Rice's lab developed the method in collaboration with the Karolinska Institute in Stockholm, Sweden.

Rice explained that under normal conditions:

"The skin contains many different types of nerve endings that distinguish between different temperatures, different types of mechanical contact such as vibrations from a cell phone and movement of hairs, and, importantly, painful stimuli."

But to their surprise, the samples that Bowsher sent them:

"Lacked all the nerve endings that we normally associated with skin sensation."

Rice and colleagues were puzzled: "how were these individuals feeling anything?"

They suggest the answer lies in the presence of sensory nerve endings in small blood vessels and sweat glands in the skin, which they had been aware of for some time.

"For many years, my colleagues and I have detected different types of nerve endings on tiny blood vessels and sweat glands, which we assumed were simply regulating blood flow and sweating," said Rice, but they didn't think they contributed anything to "conscious sensation".

But in the samples from England, they found that while the other sensory endings were missing, there were still normal types of nerve endings in the blood vessels and sweat glands.

"Apparently, these unique individuals are able to 'feel things' through these remaining nerve endings," said Rice. 

"What we learned from these unusual individuals is that there's another level of sensory feedback that can give us conscious tactile information," he added.

Rice suggested that perhaps problems in this hidden sensory system's nerve endings may help explain "mysterious pain conditions such as migraine headaches and fibromyalgia, the sources of which are still unknown, making them very difficult to treat".

"Absence of pain with hyperhidrosis: A new syndrome where vascular afferents may mediate cutaneous sensation."

David Bowsher, C. Geoffrey Woods, Adeline K. Nicholas, Ofelia M. Carvalho, Carol E. Haggett, Brian Tedman, James M. Mackenzie, Daniel Crooks, Nasir Mahmood, J. Aidan Twomey, Samantha Hann, Dilwyn Jones, James P. Wymer, Phillip J. Albrecht, Charles E. Argoff, Frank L. Rice.

PAIN - 15 December 2009 (Vol. 147, Issue 1, Pages 287-298).

DOI: 10.1016/j.pain.2009.09.007

http://www.medicalnewstoday.com/articles/173405.php

Cancer From the Kitchen? - NICHOLAS D. KRISTOF, NYTimes.com

The battle over health care focuses on access to insurance, or tempests like the one that erupted over new mammogram guidelines.

But what about broader public health challenges? What if breast cancer in the United States has less to do with insurance or mammograms and more to do with contaminants in our water or air -- or in certain plastic containers in our kitchens? What if the surge in asthma and childhood leukemia reflect, in part, the poisons we impose upon ourselves?

This last week I attended a fascinating symposium at Mount Sinai School of Medicine in New York, exploring whether certain common chemicals are linked to breast cancer and other ailments.

Dr. Philip Landrigan, the chairman of the department of preventive medicine at Mount Sinai, said that the risk that a 50-year-old white woman will develop breast cancer has soared to 12 percent today, from 1 percent in 1975. (Some of that is probably a result of better detection.) Younger people also seem to be developing breast cancer: This year a 10-year-old in California, Hannah, is fighting breast cancer and recording her struggle on a blog.

Likewise, asthma rates have tripled over the last 25 years, Dr. Landrigan said. Childhood leukemia is increasing by 1 percent per year. Obesity has surged. One factor may be lifestyle changes — like less physical exercise and more stress and fast food — but some chemicals may also play a role.

Take breast cancer. One puzzle has been that most women living in Asia have low rates of breast cancer, but ethnic Asian women born and raised in the United States don't enjoy that benefit. At the symposium, Dr. Alisan Goldfarb, a surgeon specializing in breast cancer, pointed to a chart showing breast cancer rates by ethnicity.

"If an Asian woman moves to New York, her daughters will be in this column," she said, pointing to "whites." "It is something to do with the environment."

What's happening? One theory starts with the well-known fact that women with more lifetime menstrual cycles are at greater risk for breast cancer, because they're exposed to more estrogen. For example, a woman who began menstruating before 12 has a 30 percent greater risk of breast cancer than one who began at 15 or later.

It's also well established that Western women are beginning puberty earlier, and going through menopause later. Dr. Maida Galvez, a pediatrician who runs Mount Sinai's pediatric environmental health specialty unit, told the symposium that American girls in the year 1800 had their first period, on average, at about age 17. By 1900 that had dropped to 14. Now it is 12.

A number of studies, mostly in animals, have linked early puberty to exposure to pesticides, P.C.B.'s and other chemicals. One class of chemicals that creates concern — although the evidence is not definitive — is endocrine disruptors, which are often similar to estrogen and may fool the body into setting off hormonal changes. This used to be a fringe theory, but it is now being treated with great seriousness by the Endocrine Society, the professional association of hormone specialists in the United States.

These endocrine disruptors are found in everything from certain plastics to various cosmetics. "There's a ton of stuff around that has estrogenic material in it," Dr. Goldfarb said. "There's makeup that you rub into your skin for a youthful appearance that is really estrogen."

More than 80,000 new chemicals have been developed since World War II, according to the Children's Environmental Health Center at Mount Sinai. Even of the major chemicals, fewer than 20 percent have been tested for toxicity to children, the center says.

Representative Louise Slaughter, the only microbiologist in the House of Representatives, introduced legislation this month that would establish a comprehensive program to monitor endocrine disruptors. That's an excellent idea, because as long as we're examining our medical system, there's a remarkable precedent for a public health effort against a toxic substance. The removal of lead from gasoline resulted in an 80 percent decline in lead levels in our blood since 1976 — along with a six-point gain in children's I.Q.'s, Dr. Landrigan said.

I asked these doctors what they do in their own homes to reduce risks. They said that they avoid microwaving food in plastic or putting plastics in the dishwasher, because heat may cause chemicals to leach out. And the symposium handed out a reminder card listing "safer plastics" as those marked (usually at the bottom of a container) 1, 2, 4 or 5.

It suggests that the "plastics to avoid" are those numbered 3, 6 and 7 (unless they are also marked "BPA-free"). Yes, the evidence is uncertain, but my weekend project is to go through containers in our house and toss out 3's, 6's and 7's.

http://www.nytimes.com/2009/12/06/opinion/06kristof.html?em=&pagewanted=print

Pain Connection - Chronic Pain Outreach Center

Pain Connection is a 501(c)(3) not-for-profit human service agency that provides monthly support groups, Speakers Series, supervision and training of professionals, newsletter, website, information and referrals and community outreach and education.

Pain Connection plans to establish an outreach center which will provide:

• Individual, couples and family counseling
• Weekly support groups
• Seminars and classes
• 24-hour hotline
• Case management
• Training program
• Occupational Therapy
• Library with access to the Internet
• Transportation for those in need

http://www.painconnection.org/index.html

Power Over Pain Action Network

POP Campaign

The Power Over Pain Campaign (POP) is a grassroots effort designed to engage pain care advocates - both individuals and organizations - to implement action-oriented public awareness, education, and pain policy improvement activities in their state.

• Goal: To increase the number of Americans receiving effective pain relief. 
• Mission: To inform, motivate, and harness the millions of voices of people affected by pain, in order to raise public awareness and promote the best pain policy, legislation, and practice. See Vision, Purpose and Goals.

Pain is a national healthcare crisis. It is our nation's hidden epidemic.

• Pain is the number one reason people seek medical care. More than 76.5 million Americans suffer from chronic pain, and another 25 million suffer from acute pain as a result of injuries or surgery.
• While most painful conditions can be relieved with proper treatment, people in pain face significant barriers that prevent proper assessment, diagnosis, treatment and management of their pain. Adequate pain care is necessary for improving and maintaining quality of life for people with pain and their families.

The Bottom Line: People in pain have a right to timely, appropriate pain care.

http://www.painfoundation.org/take-action/popan/background/

American Pain Foundation - Information Library

This information is provided for educational and information purposes only. APF is not engaged in rendering medical advice or professional services, and this information should not be used for diagnosing or treating a health problem. APF makes no representations or warranties, expressed or implied. Providing references to other organizations or links to other websites does not imply that APF endorses the information or services provided by them. Those organizations are solely responsible for the information they provide.

The information on this website is provided to help users find answers and support. Users may wish to print the information and discuss it with their doctor. Always consult with health care providers before starting or changing any treatment.

http://www.painfoundation.org/learn/

To Help Healing, Doctors Pay More Attention To Pain : NPR

The old notion that pain is somehow "good" for you should be put to rest for good, say health officials. They are increasingly recognizing that control of pain leads to more rapid recovery for hospitalized patients, and can even cut costs.

While pain can function as the body's alarm that something is wrong, it can also be counterproductive, says Dr. Lynn Webster, who directs the Lifetree Clinical Research and Pain Clinic in Salt Lake City.

"Most of us just want to lie there, because if we move after an operation or major trauma, it hurts. So, it does seem intuitive that's the thing to do so we can heal," Webster says.

But when patients just lie there, Webster says they're putting themselves at risk. "Patients who have good post-op pain control are able to breathe better," says Webster. Deep breaths can prevent the development of pneumonia, which can lead to sepsis and, in severe cases, require that patients be put on a ventilator. If patients can get up and walk fairly quickly after a procedure, then they also decrease their risk of blood clots in the legs which, in some cases, can be fatal.

More ...

http://www.npr.org/templates/story/story.php?storyId=120381128

A Reporter’s Guide: Covering Pain and Its Management

http://www.painfoundation.org/learn/publications/files/reporters-guide.pdf

American Pain Foundation - Pain Community News

The Pain Community News, APF's esteemed quarterly newsletter, is available as an e-publication, allowing readers to virtually flip through its pages. Take a read and be sure to click the icon for "full screen" at the bottom left  side of the screen. You can also zoom in and out as needed. Traditional PDF versions are available on this archive page

http://www.painfoundation.org/learn/publications/pain-community-news-archives.html

Exit Wounds

The American Pain Foundation (APF) today announced the release of Iraq War Veteran and Pain Advocate Derek McGinnis' first book, Exit Wounds: A Survival Guide to Pain Management for Returning Veterans and Their Families. Written in collaboration with nationally renowned pain experts, the release date for Exit Wounds coincides with September's designation as Pain Awareness Month. 

McGinnis, who sustained a traumatic brain injury, extensive shrapnel wounds, damage to his eye and amputation of his left leg above the knee from an Improvised Explosive Device (IED) while serving in the U.S. Navy in Iraq, said, "I wrote Exit Wounds because when I was struggling with horrific pain caused by my injuries, there was no guide, no map, no mentor to steer me through the minefield I was navigating. Exit Wounds contains the information my family and I desperately needed back in 2004." 

Exit Wounds is both a guide to pain management for veterans and their family members, and also the inspiring story of how one man, with the support of his family and fellow veterans, fought to survive and even thrive despite his traumatic injuries and painful path to recovery. Exit Wounds and its companion website offer veterans and family members information about: 

• Acute and chronic pain syndromes afflicting veterans 

• Treatment options, including medications, procedures, complementary therapies and other interventions 

• Strategies for self-advocating for optimal pain care 

• Medical resources inside and outside the Veterans Administration (VA) system 

• Caregiver needs, perspectives and resources 

"With hundreds of thousands of military personnel expected to return from the wars in Iraq and Afghanistan over the next few years, many of them will struggle with acute pain and face the possibility of a lifetime of chronic pain," said McGinnis. "They and their families deserve a resource to help them navigate through the barriers and obstacles that can prevent effective pain care." 

McGinnis now serves as the Military/Veterans Initiative Amputee Outreach Advocate with APF and travels the country advocating for the pain management needs of veterans, military personnel and their caregivers. He has spoken to many influential groups and individuals within the Department of Defense, Veterans Affairs, Veterans Service Organizations and Congress to bring military and veterans' pain issues to the forefront. McGinnis provides information, education, outreach, support and resources to those who are affected by pain. 

http://www.painfoundation.org/learn/programs/military-veterans/

Breaking up hurts just like physical pain - Telegraph

Researchers discovered a genetic link between physical pain and social rejection.

Psychologists at the University of California in Los Angeles have discovered that the human body deals with emotional stress in exactly the same way that it reacts to physical pain - by releasing a natural painkiller.

Scientists believe their findings suggest that the experience felt by people is the same regardless of whether their body is injured.

The researchers measured levels of a gene used by the body to regulating the painkillers.

Researchers collected saliva samples from 122 participants to assess which form of the OPRM1 pain gene they had and then measured how they reacted to different senarios.

First, participants completed a survey that measured their own sensitivity to rejection. They were asked, for example, how much they agreed or disagreed with statements like "I am very sensitive to any signs that a person might not want to talk to me."

Then the emotions of 31 people among the group were tested when they were excluded during a virtual ball-tossing computer game.

Prof Naomi Eisenberger, the study co-author, said this overlap of physical and social pain makes perfect sense.

She said: "Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them.

"Over the course of evolution, the social attachment system, which ensures social connection, may have actually borrowed some of the mechanisms of the pain system to maintain social connections."

The same portion of the brain that is responsible for the response to physical pain became activated as a result of social rejection, suggesting that, to our brains, emotions really can "hurt."

Their study also indicates that a variation in the "pain gene" is related to how sensitive a person is to social rejection.

Prof Eisenberger said: "Individuals with the rare form of the pain gene, who were shown in previous work to be more sensitive to physical pain, also reported higher levels of rejection sensitivity and showed greater activity in social pain-related regions of the brain when they were excluded."

This is the first time that it has been proved that genes involved in physical pain are linked to mentally painful times like social rejection and breaking up with a lover, she said.

The findings back up a previous study by the University of Queensland that indicated that descriptions of the agony of rejection as like a knife being thrust into the heart are more than just metaphors.

Dr Geoff MacDonald said it is no coincidence that people across different cultures and languages use similar terms to describe physical pain and what it feels like to be rejected.

http://www.telegraph.co.uk/science/science-news/6728451/Breaking-up-hurts-just-like-physical-pain.html