Sunday, May 30, 2010
Wednesday, May 19, 2010
Sunday, May 16, 2010
As a non-surgeon practicing at the busiest orthopedic surgery hospital in the country, Dr. Vijay Vad stands out. Instead of sending his patients to surgery, his goal is to keep them out of it. A sports medicine specialist at New York's Hospital for Special Surgery who regularly works with professional golfers and tennis players, Dr. Vad is a believer in the power of the mind-body connection and regularly prescribes yoga exercises and other alternative strategies for his patients. He is also the author of the new book "Stop Pain: Inflammation Relief for an Active Life,'' which is packed with practical advice and self-care options to help chronic pain patients reduce their dependence on narcotics and avoid additional medical procedures.
I spoke with Dr. Vad recently about his new book and the problem of chronic pain. Here's our conversation.
Friday, May 14, 2010
Monday, May 10, 2010
Founded in 1994 out of a shared need for better medical information and support, MedHelp is the pioneer in online health communities. The MedHelp site connects people with the leading medical experts and others who have similar experiences.
Today, MedHelp empowers over 10 million people each month to take control over their health and find answers to their medical questions. MedHelp, a privately-funded company, has over 16 years of accumulated information from doctors and other patients across hundreds of conditions. In addition, MedHelp has long-standing partnerships with the top medical institutions such as the Cleveland Clinic, National Jewish, Partners Health, and Mount Sinai. MedHelp's audience, archives, and partnerships make it a unique health destination on the Internet.
In addition to helping patients find answers to their questions, MedHelp has a robust infrastructure to help patients actively manage their health. Through its condition-specific health applications and Personal Health Records (PHRs), MedHelp members are able to track over 1500 symptoms and treatments on a daily basis as it relates to the progression of their medical condition. The ability to document and share this information with their doctors has led to better communication and more active patient engagement. MedHelp trackers are available on the website and on mobile phones through web-based browsers and iPhone apps covering both general health conditions, such as weight loss and allergies, and very specific disorders, such as infertility and diabetes.. MedHelp now has one of the largest databases of self-reported medical data, totaling 5 million data points.
Chronic pain may be caused by the inadvertent reprogramming of numerous genes in the peripheral nervous system, according to new research in a rodent model of neuropathic pain.
"Our results suggest that transcriptome reprogramming may be an important mechanism of neurological diseases such as chronic pain," Andreas Beutler, MD, from the Department of Oncology and Anesthesiology, Mayo Clinic, Rochester, Minnesota, noted in an email to Medscape Neurology. The finding could eventually lead to the identification of targets for "transcription therapy," he and colleagues conclude.
Dr. Beutler and colleagues describe their research using what they call a "paradigm-shifting" sequencing technique online May 7 in Genome Research.
Ultra–high throughput mRNA sequencing (mRNA-seq) "offers greater sensitivity, dynamic range and more efficient unbiased genetic mapping compared to the previous microarray-based methods and may be an efficient new approach to a wide array of problems in neuroscience research," Dr. Beutler explained in written statement from the Mayo Clinic.
"Importantly, our study is the first to apply the technology to a neurological disease model," Dr. Beutler told Medscape Neurology.
He and colleagues performed mRNA-seq on the L4 dorsal root ganglion of rats with chronic neuropathic pain induced by spinal nerve ligation of the neighboring L5 spinal nerve.
The researchers chose chronic pain because it is a common neurological disorder that is "incompletely understood at the functional genomic level," the team explains in their report.
Two weeks after spinal nerve ligation, 12.4% of known genes were induced and 7% were suppressed in the dysfunctional but anatomically intact L4 dorsal root ganglion, the researchers report. These alterations were still apparent 2 months after spinal nerve ligation.
Using a read cluster classifier with strong test characteristics (receiver operating characteristic area, 97%), the authors discovered 10,464 novel exons in the dorsal root ganglion potentially involved in chronic pain, including a 64-exon coreceptor for the nociceptive transmitter substance P.
According to the scientists, 21.9% of the newly discovered exons were found to be dysregulated in this animal model of neuropathic pain.
With mRNA-seq, they say they identified significantly more gene expression changes than expected based on previous microarray studies performed on dorsal root ganglion in similar rat pain models.
"Importantly, mRNA-seq demonstrates that transcriptome reprogramming in the nervous system may be more extensive than recognized by microarray studies raising the possibility that some neurological disorders such as pain may be recast in the future as diseases of altered gene expression amenable to transcription therapy."
Genome Res. Published online May 7, 2010.
Tests at University College London suggest procedures like tube feeding, injections and blood tests make pre-term infants more sensitive to pain.
The researchers say better pain relief should be given to premature babies in intensive care.
Their study is published in the journal NeuroImage.
The UCL team carrying out the study measured the brain activity of babies with an electroencephalogram (EEG) while they underwent routine heel lancing to draw blood samples.
Stronger brain activity was seen for premature infants who had been in hospital for at least 40 days, compared to healthy babies of the same age.
This suggests that the premature group are more sensitive to pain.
When both groups of babies were gently touched on the heel there was no difference in brain activity, however, suggesting that the sensitisation of preterm babies is specific to pain rather than touch.
This, say the researchers, implies that premature babies can benefit from a mother's touch - being held or cuddled - in the same way as normal infants.
The study, which was funded by the Medical Research Council, supports previous studies that reported increased sensitivity to pain in older children who were born prematurely.
Dr Rebeccah Slater, lead researcher on the study from University college London, said: "Our study shows that being born prematurely and undergoing intensive care affects pain processing in the infant brain.
"Our ability to measure brain responses to painful events will lead to a better and more informed approach to the administration of analgesia, and enable us to define optimal ways of providing pain relief in this vulnerable population."
Andy Cole, chief executive of special care baby charity Bliss, says it is imperative that babies receive good quality pain management to minimise any pain during treatment.
"Babies in intensive care for prolonged periods are usually critically ill and require these life saving procedures.
"Doctors and nurses use a range of techniques to ensure babies' pain is kept to a minimum."
Sunday, May 09, 2010
Decoding animals' facial expressions may allow researchers and veterinarians to monitor spontaneous pain over long timescales. This may also aid the discovery of painkillers, because this type of pain is similar to that experienced by humans.
Researchers typically detect pain in mice by eliciting specific reactions. Poking the hind paw, for example, causes a mouse to reflexively withdraw the paw; heating the tail makes it flick. But scientists are not agreed on how to measure unprovoked pain.
To analyse facial expressions in mice, geneticist Jeffrey Mogil at McGill University in Montreal, Canada, and his colleagues have adapted a coding system used to measure pain in infants. The work is published today in Nature Methods1.
Mogil teamed up with Kenneth Craig, a psychologist who studies human pain at the University of British Columbia in Vancouver. Expert expression-spotters from Craig's lab compared video frames of mice filmed for up to 30 minutes before and after receiving a painful injection of acetic acid.
The researchers detected five signs indicative of pain in mice. Three are similar to human responses: the eyes close and the area around them tightens, and the nose and cheeks bulge. Mice also pull back their ears and move their whiskers.
"This is the first study that has examined facial expressions of pain in non-human animals," says Craig.
The mouse grimace scale (MGS) was able to detect pain in experiments typically used by scientists. Grimaces were most pronounced for pain that lasted for a matter of minutes or hours, and for discomfort in joints and internal organs. Superficial harm such as immersing the tail in hot water evoked fewer grimaces. Mice and humans show similar variability in pain response, Mogil says.
Pained expressions differed from those associated with stress and illness, the team found. In addition, more harmful stimuli drew more pronounced grimaces, and pain relievers diminished them.
Mice with a mutation that has been linked to migraines in humans showed pained expressions that subsided when they were given an anti-migraine drug. "I'm very confident that we're measuring pain here," Mogil says.
Lars Arendt-Nielsen, a pain expert at Aalborg University in Denmark, is not convinced that the team has ruled out other emotions, such as fear, but he recognizes the benefits of the approach. "You can probably look into new pain conditions which we have not been capable of looking into with previous methods," he says.
Arendt-Nielsen also questions whether the scale will apply to other animals, because pain reactions differ between species. But Mogil thinks it will. "I'd be incredibly surprised if a version of this scale doesn't work in every mammal," he says.
Next, Mogil would like to compare his method with others used to evaluate painkillers, and test different doses used to treat postoperative discomfort in animals. Currently, it's not known whether prescribed doses really work. "We think in a sense that we can rewrite the veterinarian rule book," he says.
"It has been said that the mystery of chronic pain can be found in the history. In The Pain Detective: Every Ache Tells a Story, Dr. Finestone has accumulated and described a series of medical stories (histories) that highlight the complex mind-body-environment interaction that can lead to chronic pain and suffering. With mysteries unlocked, Dr. Finestone presents enlightening and practical information to help people manage their pain and regain control of their lives. This book is certain to be of great value to both those that suffer and those that treat the sufferers."
+ Stuart M. Weinstein, M.D., Editor-in-Chief, PM&R and Clinical Professor, Departments of Rehabilitation Medicine, Orthopaedic Surgery, and Neurological Surgery, University of Washington
"Hillel Finestone belongs to that rare breed of physical medicine specialist who doesn't separate the mind from the body, because he has the wisdom to know that in real life no such separation can exist. In The Pain Detective he applies that wisdom to painful conditions like fibromyalgia, and just as a good detective, illuminates their contributing causes by shining his light in many recesses of the human physique and psyche. The result is a book that heals."
+ Gabor Maté M.D., author of When The Body Says No: The Cost of Hidden Stress
"This book is a MUST READ for anyone experiencing ongoing pain, Dr. Finestone takes a biopsychosocial (often called a mind-body) approach to understanding pain, which is the key ingredient in successfully treating pain and pain-associated disability."
+ Lonnie Zeltzer, M.D., Director, Pediatric Pain Program, Mattel Children's Hospital at UCLA
Wednesday, May 05, 2010
The Overlapping Conditions Alliance is a group of independent nonprofit organizations seeking to advance the scientific, medical and policy needs of individuals affected by medical conditions that frequently overlap.
Millions of Americans suffer from chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis, irritable bowel syndrome, temporomandibular joint and muscle disorders, and vulvodynia. Current research indicates that these conditions frequently coexist or 'overlap,' yet all of the disorders are poorly understood. As a result, health care providers receive little training in these types of disorders and many patients are misdiagnosed and receive inappropriate treatment. Research on the overlap of these conditions is in its infancy, so we don't know how/why they are connected. There are many unanswered questions. Some people suffer from two conditions, while others have three or more. In some cases, individuals suffer from one condition for many years before developing a second or third; in other cases, individuals experience symptoms of several conditions simultaneously. These disorders make life very difficult for millions of sufferers and their families. In addition, they cost the United States tens of billions of dollars each year in medical expenses and lost productivity. An expanded federal research effort is urgently needed to investigate common underlying mechanisms and risk factors for these disorders, so that preventive strategies and more effective treatments can be developed.
Click for more information on some of these disorders:
Tuesday, May 04, 2010
Gender appears to play a role in the risk of abuse of prescription pain drugs, a study shows.
Predictors of such abuse are different in men and women, researchers say, and knowing this could help doctors adopt treatment plans that are less likely to cause misuse of opioid medications.
The finding comes from a study involving 662 chronic noncancer patients taking opioid drugs for pain relief.
Researchers say misuse by women seems to be closely related to psychological distress. Prescription pain drugs are more likely to be misused by men who have social and behavioral problems.
"Since little has been published about gender differences and misuse of prescription pain medication, it is valuable to document whether risk factors for abuse are gender specific to some degree," says study researcher Robert N. Jamison, PhD, a clinical psychologist at Harvard's Brigham and Women's Hospital.
The study shows that men and women have similar frequencies of aberrant drug behavior but different risk factors for abuse of opioids.
Women who misuse pain drugs are more likely "to admit to being sexually or physically abused or have a history of psychiatric or psychological problems," Jamison says.
Women who are being treated for pain not caused by cancer and who exhibit signs of significant stress should be treated for mood disorders and counseled on dangers of relying on pain pills to help them sleep or reduce stress, the researchers say.
Men taking pain pills should be closely monitored for suspected behavioral problems, Jamison says. In addition, their pills should be counted to check adherence, and frequent urine screens also should be done.
Jamison and colleagues write in the study that the use of opioids for chronic pain has been growing, and that between 3% and 16% of the population has a substance use disorder.
Indeed, some pain centers that dispense opioids "are overwhelmed with patients who are known or suspected to be abusing" their medications, the researchers write.
The study involved patients who had been prescribed opioids for chronic noncancer pain; about half the participants were men, half were women.
Five months into the study they were interviewed and had to submit a urine sample. Physicians also completed a substance misuse behavior checklist.
The researchers write that women in the study tended to display signs of emotional issues and affective distress, compared with men.
Men tended to show signs of worrisome behaviors, such as association with other people who abused drugs and alcohol and engaging in criminal behavior.
For women, a history of sexual abuse was an issue in later misuse of prescription drugs. "These results are in agreement with past research that highlighted the importance of sexual and physical abuse history in predicting opioid misuse," the researchers write. "These same studies also showed that women with a significant history of anxiety and depression tend to do less well in properly managing opioids prescribed for pain, possibly because of the tendency to self-medicate a mood disorder using opioids."
The researchers also say that past research has suggested that women may be more open and truthful about behaviors and to seek psychological help than men.
"Given the prominence of sex differences in a variety of pain-related processes, we may eventually arrive at a method for tailoring risk assessment and risk-reducing interventions in part as a function of gender," the researchers say, adding that more research is called for by their study.
The study is published in the April issue of The Journal of Pain.
This article is part of our Monday series How You Can Benefit from Psychological Pain Management. This week we'll look at why comprehensive pain treatment – seeing several different types of health care providers – works best.
The 2 main reasons to work with a health care team are:
1. Pain is complicated and takes a team of experts to help get you better
Pain is complicated and is caused by many different factors. On the one hand, unfortunately, that mean there's usually not 1 simple treatment that will cure you. However, on the positive side, that means there are multiple ways to improve things.
Seeing different types of treaters – doctor, psychiatrist/psychologist, physical therapist, alternative medicine practitioner – lets each person add something to your treatment. Hopefully, when all the treatments add up, you'll be moving towards a better place.
Many times treatments work in concert with each other. For example, anesthetic injections work better is you're not overly anxious or depressed. So treating anxiety can help medication be more effective.
2. Seeing a team lets each provider focus on what (s)he does best
In a sense, this is the flip-side of #1. But to expand on this, it means that you utilize each person on your health care team to your best advantage. Your appointment times are not unlimited, so focusing in on what each person does best means you're taking advantage of the expertise of each person.
As a psychiatrist, I notice this issue most often related to anxiety or depression. If you're seeing a psychiatrist or psychologist, you can work on these issues in therapy. This lets you spend time with your medical pain management doctor (neurologist, anesthesiologist, rheumatologist, etc) talking about medications, injections and other procedures, instead of unloading your stress with them. Often they don't have time to do both. So you get appropriate treatment, and they don't get overwhelmed trying to treat problems they're not equiped for.
2 studies that look at comprehensive treatment are:
- "Rational integration of pharmacologic, behavioral and rehabilitation strategies in the treatment of chronic pain," Am J Phys Med Rehabil 2005, 84: S64-76.
- "Efficacy of multidisciplinary pain centers in the treatment of chronic pain," Prog Pain Res Manage 1996, 7:257-74.
Other articles in this series:
- Why comprehensive treatment works better
- Benefits of a psychiatric evaluation
- Treatment of psychiatric symptoms
- Using psychiatric medications for pain
- Learning psychological skills
- Making positive behavioral changes
- Making positive psychological changes
- Benefits of supportive therapy
- Benefits of a pain support group
- New brain-based treatments
Researchers have discovered the body's own "heat messenger," which helps nerves feel pain, and said yesterday they hope to use it to design a new, safer class of painkillers.
They found heat activates basic fatty acids similar to capsaicin, the compound that gives chili peppers their kick, and found two potential ways to block the sensation.
"For the first time we have the opportunity to try to block pain at its source," Dr. Kenneth Hargreaves of The University of Texas Health Science Center at San Antonio, who led the study, said in a telephone interview.
He said his team is now working to develop either a pill that people could take to block the effects of these natural "heat messengers," or engineered immune system proteins called monoclonal antibodies that could be infused to mop them up.
Such an approach should work on any kind of pain caused by inflammation, he said -- arthritis, cancer or injury. He is uncertain about its effects in other types of pain called neuropathies.
Most painkillers mask pain but do not affect its source. Narcotics or morphine are examples and are addictive and deadly. Non-steroidal anti-inflammatory drugs such as aspirin can help ease the inflammation that causes arthritis pain or a headache but have side-effects.
Aspirin can cause deadly bleeding, related drugs called COX-2 inhibitors sometimes cause heart problems, acetaminophen, also known as paracetamol, can damage the liver. None are highly effective.
Writing in the Journal of Clinical Investigation, Hargeaves and colleagues said they first looked for the basic cause of the pain and narrowed it down to the capsaicin receptor, a molecular doorway on nerve cells.
"The capsaicin receptor is like the master lock in our pain neurons," Hargreaves said.
"We have mice now with a genetic deletion of this master lock. Those without it show almost no pain from inflammation or cancer or burn injuries, so that we know that this receptor is critically important in terms of how the body responds to injury."
The capsaicin in red hot chili peppers unlocks this master lock, Hargreaves said. He wanted to find a way to block the keyhole, which is called transient potential vanilloid 1 or TRPV1.
Tests on mouse tissue showed heat did not directly activate pain neurons. Instead, in response to heat, cells create their own natural capsaicins called oxidized linoleic acid metabolites or OLAMs. The report is available at http:/www.jci.org/articles/view/41678?key-9c726bad5dba215ac93d.
In a commentary on the findings, David Brown and Gayle Passmore, at University College London, called the newly discovered pain compound a "heat messenger."
Hargeaves said his team has some candidates for both a pill and an antibody but "I am not at liberty to discuss them." The university has a patent application for both potential routes.
While researchers can design drugs that will fit like a puzzle piece into a cell receptor, or screen libraries of existing compounds to see if one might work, Hargreaves said his team did neither.
"We did it the old fashioned, stupid way. We got lucky," he said.
"Our findings are truly exciting because they will offer physicians, dentists and patients more options in prescription pain medications. In addition, they may help circumvent the problem of addiction and dependency to pain medications, and will have the potential to benefit millions of people who suffer from chronic pain every day."
Monday, May 03, 2010
The Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine and the body among medical professionals and the general public. This model is founded on providing a free online technology platform that is collaborative, interdisciplinary and transparent. Read more about the model.
Users of the platform include physicians, consumers, medical and scientific journals, medical schools, research institutes, medical associations, hospitals, for-profit and non-profit organizations, expert patients, policy makers, students, non-professionals taking care of loved ones, individual medical professionals, scientists, etc.
As Medpedia grows over the next few years, it will become a repository of up-to-date unbiased medical information, contributed and maintained by health experts around the world, and freely available to everyone. The information in this clearinghouse will be easy to discover and navigate, and the technology platform will expand as the community invents more uses for it.http://www.medpedia.com/news_analysis/search?prot=true&bq=pain&commit=Search
Saturday, May 01, 2010
In a University of Michigan Health System study, 1 out of 3 patients with chronic pain reported using complementary and alternative medicine therapies such as acupuncture and chiropractic visits for pain relief.
Socioeconomic factors – primarily race and age – played a large role in the use of alternative therapy in chronic pain patients, the study showed. Whites used alternative modalities more frequently than blacks and elderly adults had a higher frequency of using alternative therapies than younger adults.
According to the lead author, Carmen R. Green, M.D., U-M professor of anesthesiology and obstetrics and gynecology and associate professor of health management and policy, this pattern may be due to alternative medicine therapies usually attracting individuals with higher education levels and income, or the pattern could be a result of differences in insurance coverage.
Also, as people age, there is a greater chance that they will deal with chronic pain, therefore as age increases, so does the likelihood that people will seek alternative therapies to deal with the pain.
The study which appears in the journal, Pain Medicine, highlights the importance of complementary and alternative medicine, its increasing usage, its economic impact, and concerns about safety and effectiveness.
To track the link between pain and alternative medicine, Green and S. Khady Ndao-Brumblay, PharmD, MSc, doctoral student in health management and policy at the U-M School of Public Health, looked at the ethnic and racial disparities in treating chronic pain in 5,750 adults over a six-year period.
Socioeconomic characteristics, medical history, physical and social health characteristics and pain-related symptoms in both black and white adults with chronic pain were collected with the Pain Assessment Inventory Narrative to assess the treatment methods.
The types of practitioner-based alternative therapy examined included manipulation therapy such as chiropractic or physical therapy procedures, biofeedback – instruments that control the heart rate, blood pressure and brain waves for relaxation purposes – and acupuncture.
These three alternative medicine therapy services were used most often by people with chronic pain, but who uses the therapy depends on the type of modality.
"This research may provide important new insights into the use of alternative therapies for people living with chronic pain. It helps us understand more about who is using CAM therapies, and also prompts a discussion on how these methods work and on whom they work best," Green says.
Of those observed, 35 percent reported using at least one form of complementary and alternative medicine therapy with 25 percent using manipulation techniques, 13 percent using biofeedback and 8 percent acupuncture.
Green, U-M pain medicine physician and anesthesiologist, says complementary and alternative medicine therapies can be beneficial in treating pain, but further studies are needed to determine just how effective they are and how great the risks and benefits are. Since alternative therapy is often used in combination with other methods, such as regular physician visits and traditional medications, she warns patients should inform their doctors when using these therapies.
"It's helpful for physicians to know that patients are using these therapies so that we can minimize any risks or side effects associated with them," Green says.
Because chronic pain has been found to double the odds of seeking alternative services, this along with decreased access to and negative perceptions about pain treatment, may be one of the primary reasons for seeking this type of therapy over conventional medicine. However, more research needs to be done to confirm this.
"Unfortunately patients are often reluctant to share information regarding alternative therapy usage with health care providers, but discussions and awareness of alternative therapy use in pain patients may improve the quality of pain care and patient safety," Green says.