Wednesday, June 05, 2019

What Was the Cause of the Excruciating Pain in His Shoulders and Hips? - The New York Times

As the physician prepared to leave the exam room, the patient's wife spoke up: "Doctor, my husband won't tell you this, but he is suffering," the woman said, her voice cracking. Dr. Timothy Quan, a rheumatologist in central Connecticut, looked at the 69-year-old man he'd been caring for over the past several months. The man gave a brisk nod. It was true. The past few weeks had been a nightmare of pain.

Six months earlier, the patient woke up with a sore, swollen right hand. He figured he must have injured it a few days before when he cleared out a pile of wood in his backyard. He mentioned it to his primary-care physician a couple of weeks later when he went in for a routine exam. The doctor prescribed some ibuprofen and suggested that maybe he was too old for that kind of heavy labor.

The ibuprofen helped but didn't stop the pain from spreading to both shoulders and down his hips and legs. By the time he went back to his doctor a few days later, every muscle, every ligament, every bone in his body seemed to ache. It was worse in the morning, when he was so stiff he could hardly get out of bed.

The patient lived in rural Connecticut, so his physician figured it was probably Lyme disease. He sent him to be tested but felt confident enough in the diagnosis to start him on doxycycline, the antibiotic used to treat most of the infections carried by ticks.

The antibiotic didn't help — he was still in a lot of pain. So his doctor called in a week of prednisone. The aches almost disappeared with the very first pill. They came back with a vengeance, though, when the prescription ended. He tried to tough it out, but the pain worsened every day.

More …

https://www.nytimes.com/2019/06/05/magazine/hip-shoulder-pain-polymyalgia-rheumatica-diagnosis.html

Friday, May 31, 2019

These Mole Rats Felt No Pain, Even From Wasabi’s Burn - The New York Times

If you've ever taken a big bite of wasabi, you know what comes next: a painful zing that creeps over your whole scalp.

You aren't the only animal that feels this way. The condiment's sinus-burning kick comes from a chemical compound called allyl isothiocyanate, or AITC, that actively damages proteins within cells. Flies and flatworms shun it, as do miceand wolf spiders. "Practically every animal you look at will avoid AITC," said Gary Lewin, a molecular physiologist at the Max Delbrück Center for Molecular Medicine in Berlin.

But there is one exception. In a paper published Thursday in Science, scientists including Dr. Lewin showed that the highveld mole rat, a rodent found in South Africa, is entirely impervious to the substance.

The study "demonstrates the power of studying naturally occurring differences in pain sensitivity," said Ewan St. John Smith, a neurobiologist at the University of Cambridge, who was not involved in the research. The work could eventually lead to more effective pain treatment in humans.

More ...

https://www.nytimes.com/2019/05/30/science/mole-rats-pain.html

Wednesday, May 22, 2019

Millions Take Gabapentin for Pain. But There’s Scant Evidence It Works. - The New York Times

One of the most widely prescribed prescription drugs, gabapentin, is being taken by millions of patients despite little or no evidence that it can relieve their pain.

In 2006, I wrote about gabapentin after discovering accidentally that it could counter hot flashes.

The drug was initially approved 25 years ago to treat seizure disorders, but it is now commonly prescribed off-label to treat all kinds of pain, acute and chronic, in addition to hot flashes, chronic cough and a host of other medical problems.

The F.D.A. approves a drug for specific uses and doses if the company demonstrates it is safe and effective for its intended uses, and its benefits outweigh any potential risks. Off-label means that a medical provider can legally prescribe any drug that has been approved by the Food and Drug Administration for any condition, not just the ones for which it was approved. This can leave patients at the mercy of what their doctors think is helpful.

Thus, it can become a patient's job to try to determine whether a medication prescribed off-label is both safe and effective for their particular condition. This is no easy task even for well-educated doctors, let alone for desperate patients in pain.

Two doctors recently reviewed published evidence for the benefits and risks of off-label use of gabapentin (originally sold under the trade name Neurontin) and its brand-name cousin Lyrica (pregabalin) for treating all kinds of pain.

(There is now also a third drug, gabapentin encarbil, sold as Horizant, approved only for restless leg syndrome and postherpetic neuralgia, which can follow a shingles outbreak.)

The reviewers, Dr. Christopher W. Goodman and Allan S. Brett of the University of South Carolina School of Medicine, found the drugs, called gabapentinoids, wanting in most cases for which they are currently being prescribed.

More ...

https://www.nytimes.com/2019/05/20/well/live/millions-take-gabapentin-for-pain-but-theres-scant-evidence-it-works.html?

Monday, May 20, 2019

Why Does The Brain Connect Pain With Emotions? : Shots - Health News : NPR

When Sterling Witt was a teenager in Missouri, he was diagnosed with scoliosis. Before long, the curvature of his spine started causing chronic pain.

It was "this low-grade kind of menacing pain that ran through my spine and mostly my lower back and my upper right shoulder blade and then even into my neck a little bit," Witt says.

The pain was bad. But the feeling of helplessness it produced in him was even worse.

"I felt like I was being attacked by this invisible enemy," Witt says. "It was nothing that I asked for, and I didn't even know how to battle it."

So he channeled his frustration into music and art that depicted his pain. It was "a way I could express myself," he says. "It was liberating."

Witt's experience is typical of how an unpleasant sensation can become something much more complicated, scientists say.

More …

https://www.npr.org/sections/health-shots/2019/05/20/724136568/how-the-brain-shapes-pain-and-links-ouch-with-emotion

Thursday, May 16, 2019

How Tiger Woods Won the Back Surgery Lottery - The New York Times

Few would have predicted that Tiger Woods would be playing in the P.G.A. Championship this week. He had three failed back surgeries, starting in 2014. He had taken opioids. His astonishing career seemed over.

Then he had one more operation, a spinal fusion, the most complex of all, in 2017. And last month he won the Masters, playing the way he used to.

An outcome like his from fusion surgery is so rare it is "like winning the lottery," Dr. Sohail K. Mirza, a spine surgeon at Dartmouth, said.

The idea behind spinal fusion is to remove a disk — a ring of fibers filled with a nerve-cushioning jelly that joins adjacent spine bones — and fuse the spine together, a procedure that almost inevitably means trading flexibility for stability and, the patient hopes, an existence with less pain.

That was all Woods was looking for when he decided to go ahead with fusion as a last resort — a "normal life" is how he put it. He got that and much more, including a new green blazer, though the lesson that most surgeons say Woods's experience teaches isn't that fusion surgery is a panacea but how much active rehabilitation and physical therapy the procedure requires for it to work.

"If you look at it simplistically, what does fusion do? It provides mechanical support," said Dr. Charles A. Reitman, co-director of the Spine Center at the Medical University of South Carolina. "If they are missing mechanical support and that is the pure cause of the problem, then they will get better."

People with a broken spine, for example, or scoliosis, which is severe spinal curvature, or spondylolisthesis, in which vertebrae slip out of place, tend to have terrific results, he said.

But those are a tiny minority of fusion patients. The vast majority of fusion procedures are performed on patients with one or more degenerated disks, disks that are worn out, dehydrated, stiff and friable. And when those disks move, patients' backs can ache.

More ...

https://www.nytimes.com/2019/05/15/sports/how-tiger-woods-pga-back-surgery.html

Monday, April 29, 2019

Virtual Reality as Therapy for Pain - The New York Times

I was packing up at the end of a family vacation in Florida when my back went into an excruciating spasm unrelieved by a fistful of pain medication. As my twin sons, then 8 years old, wheeled me through the airport, one of them suggested, "Mom, if you think about something else, it won't hurt so much."

At the time, I failed to appreciate the wisdom of his advice. Now, four decades later, a sophisticated distraction technique is being used to help patients of all ages cope with pain, both acute and chronic. The method, called Virtual Reality Therapy, goes beyond simple distraction, as might result from watching television. Rather, it totally immerses the patient in an entertaining, relaxing, interactive environment that so occupies the brain, it has no room to process pain sensations at the same time.

"It's not just a distraction — it's like an endogenous narcotic providing a physiological and chemical burst that causes you to feel good," said Jeffrey I. Gold, director of the pediatric pain management clinic at Children's Hospital Los Angeles. "It's different from reading a book or playing with a toy. It's a multisensory experience that engages a person's attention on a much deeper level."

Virtual Reality Therapy is the new kid on the block for pain management, now gradually growing in use as the opioid epidemic continues to soar and the price of the needed equipment has plummeted. VR, as it is called, has been most widely and successfully used so far to help children and adults weather acute pain, as can accompany an IV insertion or debridement of burns. But it can also enhance the effectiveness of established techniques like physical therapy, hypnosis and cognitive behavioral therapy to treat debilitating chronic pain.

More ...

https://www.nytimes.com/2019/04/29/well/live/virtual-reality-as-therapy-for-pain.html

Sunday, April 14, 2019

National Pain Report – What You Don't Know Can Hurt You

The National Pain Report is the leading online news site dedicated to the coverage of chronic pain. We feature the latest developments in the treatment of chronic pain, public policy impacting chronic pain as well comments from leading pain specialists and columns from chronic pain sufferers.

http://nationalpainreport.com/

Wednesday, April 03, 2019

Why the sexes don’t feel pain the same way

Robert Sorge was studying pain in mice in 2009, but he was the one who ended up with a headache.

At McGill University in Montreal, Canada, Sorge was investigating how animals develop an extreme sensitivity to touch. To test for this response, Sorge poked the paws of mice using fine hairs, ones that wouldn't ordinarily bother them. The males behaved as the scientific literature said they would: they yanked their paws back from even the finest of threads.

But females remained stoic to Sorge's gentle pokes and prods1. "It just didn't work in the females," recalls Sorge, now a behaviourist at the University of Alabama at Birmingham. "We couldn't figure out why." Sorge and his adviser at McGill University, pain researcher Jeffrey Mogil, would go on to determine that this kind of pain hypersensitivity results from remarkably different pathways in male and female mice, with distinct immune-cell types contributing to discomfort2.

Sorge and Mogil would never have made their discovery if they had followed the conventions of most pain researchers. By including male and female mice, they were going against the crowd. At the time, many pain scientists worried that females' hormone cycles would complicate results. Others stuck with males because, well, that's how things were done.

Today, inspired in part by Sorge and Mogil's work and spurred on by funders, pain researchers are opening their eyes to the spectrum of responses across sexes. Results are starting to trickle out, and it's clear that certain pain pathways vary considerably, with immune cells and hormones having key roles in differing responses.

More ...

https://www.nature.com/articles/d41586-019-00895-3?

Tuesday, April 02, 2019

Acute to Chronic Pain Signatures | NIH Common Fund

This program will develop a set of objective biomarkers that provide a "signature" to predict a transition from acute to chronic pain, in order to accelerate therapy development and ultimately to guide pain prevention strategies. These biomarkers are greatly needed as the number of people who transition from acute to chronic pain after an acute pain event is surprisingly high. This high prevalence of chronic pain in the US has in part contributed to the current opioid epidemic.

A major challenge in pain management is preventing chronic pain from occurring after an acute pain event. For most people, acute pain resolves as the injury or trauma that caused it heals. Yet in many other people, acute pain from injury, surgery, or disease persists beyond the initial insult, and can last for years or throughout life. Many drugs, while effective early on, lose efficacy over time and make the transition from acute to chronic pain worse. In those who transition to chronic pain, maladaptive changes occur throughout the nervous system. Our ability to reverse these changes is very limited. Our lack of understanding of the mechanisms of transition to chronic pain is a major gap in knowledge that limits development of effective preventive therapies. The ability to identify those at risk for transitioning to chronic pain could inform future clinical trials, improve success of trials, and transform acute pain treatment approaches for prevention of chronic pain.

The Acute to Chronic Pain Signatures program will use advances in imaging, high-throughput biomedical experiments ('omics), sensory testing, and psychosocial assessments to explore a range of characteristics from patients who transition or are resilient to chronic pain. The study will follow two groups from the time of acute pain event over a period of six months. One group will have post-operative pain and the other will have musculoskeletal trauma. The key deliverable of the program is a comprehensive data set for the research communities that should reveal "signatures" predictive of transition versus resilience to chronic pain.

***

NIH seeks input from the scientific community on specific candidate molecules, tests, patient reported outcomes, psychosocial factors, health record data, and/or other characteristics that could potentially serve as high value biomarkers for predicting acute to chronic pain transition and/or resilience which should be considered for inclusion as outcome measures to collect in the studies. All recommendations should be backed up with a rationale and citations from peer reviewed literature or other justification. Potential candidates could include, but are not limited to, the following:

• Specific electronic health record information, including co-occurring conditions, prescription information, etc.
• Specific patient reported outcomes (e.g., PROMIS measures)
• Candidate psychosocial factors
• CNS or other imaging features
• Sensory tests for mechanical, temperature, or other types of pain
• Actinography for sleep and circadian rhythms and locomotor activity
• Molecules that can be obtained in patient blood, serum, or other non-invasively collected fluids
• Candidate genetic variants

https://commonfund.nih.gov/pain

Sunday, March 31, 2019

How Pain Tolerance and Anxiety Seem to Be Connected - The New York Times

An article this week about Jo Cameron, who has lived for 71 years without experiencing pain or anxiety because she has a rare genetic mutation, prompted questions from New York Times readers.

The notion that the same gene could be responsible for the way a person processes physical and psychological pain left many perplexed: Aren't they totally different? Or does her story hint that sensitivity to one type of pain might be intertwined with sensitivity to another?

Childbirth, Ms. Cameron said, felt like "a tickle." She often relies on her husband to alert her when she is bleeding, bruised or burned because nothing hurts.

When someone close to her has died, she said, she has felt sad but "I don't go to pieces." She cannot recall ever having been riled by anything — even a recent car crash. On an anxiety disorder questionnaire, she scored zero out of 21.

"I drive people mad by being cheerful," she said.

Here's a bit about what's known.

More ...

https://www.nytimes.com/2019/03/30/health/pain-anxiety-jo-cameron.html

At 71, She’s Never Felt Pain or Anxiety. Now Scientists Know Why. - The New York Times

She'd been told that childbirth was going to be painful. But as the hours wore on, nothing bothered her — even without an epidural.

"I could feel that my body was changing, but it didn't hurt me," recalled the woman, Jo Cameron, who is now 71. She likened it to "a tickle." Later, she would tell prospective mothers, "Don't worry, it's not as bad as people say it is."

It was only recently — more than four decades later — that she learned her friends were not exaggerating.

Rather, there was something different about the way her body experienced pain: For the most part, it didn't.
Scientists believe they now understand why. In a paper published Thursday in The British Journal of Anaesthesia, researchers attributed Ms. Cameron's virtually pain-free life to a mutation in a previously unidentified gene. The hope, they say, is that the finding could eventually contribute to the development of a novel pain treatment. They believe this mutation may also be connected to why Ms. Cameron has felt little anxiety or fear throughout her life and why her body heals quickly.

More ...

https://www.nytimes.com/2019/03/28/health/woman-pain-anxiety.html?

Monday, March 18, 2019

Opinion | Is Pain a Sensation or an Emotion? - The New York Times

The United States uses a third of the world's opioids but a fifth of Americans still say they suffer from chronic pain. The only demonstrable effect of two decades of widespread prescription of opioids has been catastrophic harm. With more than 47,000 Americans dying of opioid overdoses in 2017 and hundreds of thousandsmore addicted to them, it was recently reported that, for the first time, Americans were more likely to die of opioids than of car accidents.

This has forced many to take a step back and ponder the very nature of pain, to understand how best to alleviate it.

The ancient Greeks considered pain a passion — an emotion rather than a sensation like touch or smell. During the Dark Ages in Europe, pain was seen as a punishment for sins, a spiritual and emotional experience alleviated through prayers rather than prescriptions.

In the 19th century, the secularization of Western society led to the secularization of pain. It was no longer a passion to be endured but a sensation to be quashed.

More ...

https://www.nytimes.com/2019/03/16/opinion/sunday/pain-opioids.html?

Sunday, March 10, 2019

Could The Cure For A Rare Chronic Pain Disorder Be ... More Pain? : Shots - Health News : NPR

There's a before, and there's an after.

In the before, it was a relatively normal night. The kind of night any 14-year-old girl might have.

Devyn ate dinner, watched TV and had small, unremarkable interactions with her family. Then, around 10 o'clock, she decided to turn in.

"I went to bed as I normally would, and then all of a sudden ... my hips... they just hurt unimaginably!" Devyn says. "I started crying, and I started shaking."

It was around midnight, but the pain was so intense she couldn't stop herself — she cried out so loudly she woke her mother, Sheila. Together, they did everything they could to neutralize the pain — stand up, lie down, hot bath, pain medication. But there was no escape, not for Devyn, and so not for Sheila.

"You go to cancer first, right? It's like, 'OK, maybe you have cancer, maybe it's a tumor?' " Sheila says.

When she was calm enough to reason with herself, Sheila decided cancer was improbable but wondered what was going on? The only thing they could think of was that the hip pain was somehow related to the minor knee surgery Devyn had gotten a few months before — she had broken the tip of her distal femur one day during dance practice.

So as usual, Sheila snapped to attention to solve the problem. It was 2016 — surely modern medicine could fix this. (NPR is not using Devyn's or Sheila's last name to protect Devyn's privacy as a minor discussing her medical treatment.)

They started by calling Devyn's surgeon, but the surgeon had no explanation for the pain. He renewed Devyn's prescription for Percocet and wrote a new prescription for tramadol. But the pain only got worse, so they lined up more appointments: their pediatrician, a naturopath, a pain specialist, a sports medicine doctor.

Every doctor's visit was the same. The doctor would ask Devyn about her pain: Where was it, and what was her pain number on a scale from 1 to 10? Then the doctor would order some tests to find the pain's cause.

But no matter where the doctors looked in Devyn, all they saw was a perfectly normal body.

"You are healthy. Nothing is wrong." Those are the words the doctors said to Devyn and Sheila over and over again. It made no sense. And it felt, paradoxically, like the more attention they gave to the pain, the bigger the pain grew.

More ...

https://www.npr.org/sections/health-shots/2019/03/09/700823481/invisibilia-for-some-teens-with-debilitating-pain-the-treatment-is-more-pain?

Friday, February 01, 2019

Managing Children’s Pain After Surgery - The New York Times

Pain control in infants and children has come a long way over the past few decades. Experts know how to provide appropriate anesthesia when children need surgery and understand the ways that even very young children express distress when they're hurting afterward. There is a lot of evidence about reducing the pain and anxiety that can accompany immunizations and blood draws, and there is increasing expertise about helping children who struggle with chronic pain.

But today's parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.

Change doesn't always come easily in medicine, so there's a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery,ideally with a child life specialist, and it means careful attention to the child's pain afterward, with parents well backed up by medical specialists.

More ...

https://www.nytimes.com/2019/01/07/well/family/managing-childrens-pain-after-surgery.html

Thursday, January 24, 2019

Spinal Fractures Can Be Terribly Painful. A Common Treatment Isn’t Helping. - The New York Times

Scientists warned osteoporosis patients on Thursday to avoid two common procedures used to shore up painful fractures in crumbling spines.

The treatments, which involve injecting bone cement into broken vertebrae, relieve pain no better than a placebo does, according to an expert task force convened by the American Society for Bone and Mineral Research.

The task force noted that the pain goes away or diminishes within six weeks without the procedure. Patients should take painkillers instead, the experts said, and maybe try back braces and physical therapy.

More ...

https://www.nytimes.com/2019/01/24/health/spinal-fracture-treatment.html

Sunday, January 20, 2019

Repeated pain makes men more sensitive — but not women | CBC Radio

Dr. Loren Martin and his colleagues were actually investigating another question when they discovered this surprising result. They were measuring how multiple sources of pain changed pain perception.

In experiments, in mice they used a heat probe that created an mild level of heat on the mouse's feet. Then they gave the mice a dose of vinegar to upset their stomachs. The mice, unsurprisingly, didn't like it.

The suprise came when they they repeated the experiment. The male mice showed more stress when brought back to the location of the experiment, and had stronger responses to the heat stimuli - they were more sensitivity to the pain. The female mice showed no extra stress or sensitivity.

Researchers shone a mild heat probe at the mice's feet to induce a slight pain in the experiment. (Sana Khan)
They then ran a similar experiment on humans.

They used the same combination of stimuli - heat on the forearm, and an uncomfortably tight blood pressure cuff over the bicep. They left the cuff on for about 20 minutes and had the participants do arm exercises to increase the pain.

The participants came back the next day and were sent to the same environment where they wore the blood pressure cuff to repeat the heat probe experiment. This time, the men reported feeling more pain from the heat probe, while nothing changed for the women. It was the same sex difference that they'd seen in the mice.

More ...

https://www.cbc.ca/radio/quirks/jan-19-2019-tuskless-elephants-room-temperature-superconductors-how-space-changed-a-man-and-more-1.4981750/repeated-pain-makes-men-more-sensitive-but-not-women-1.4981763

Monday, January 14, 2019

Managing Children’s Pain After Surgery - The New York Times

Pain control in infants and children has come a long way over the past few decades. Experts know how to provide appropriate anesthesia when children need surgery and understand the ways that even very young children express distress when they're hurting afterward. There is a lot of evidence about reducing the pain and anxiety that can accompany immunizations and blood draws, and there is increasing expertise about helping children who struggle with chronic pain.

But today's parents may be shocked to learn that was not always the case. As recently as the early 1980s, the pain of children and infants was thought to be different from that of adults and was sometimes treated differently, or sometimes not treated at all.

Change doesn't always come easily in medicine, so there's a certain onus on parents to make sure that their children get state-of-the-art pain management around procedures, large and small. That means preparation before any planned surgery, ideally with a child life specialist, and it means careful attention to the child's pain afterward, with parents well backed up by medical specialists.

More ...

https://www.nytimes.com/2019/01/07/well/family/managing-childrens-pain-after-surgery.html