Friday, February 27, 2009

Pain Resource Center :: Pain Assessment Tools

This section includes various tools to assess pain and its management.  Specifically, pocket reference cards,      rating scales, assessment packets, chart forms, database tools, home health flow sheets, chart documentation packets, and tools for infant and pediatric pain assessment are among the resources available.

Thursday, February 26, 2009

Pain-Blog Carnival February 2009 | How To Cope With Pain Blog

CRPS/RSD A Better Life provides an overview of mirror therapy in A Novel Approach To Pain Treatment.

A new contributor, Against the 'Graine (great name!) looks at Keeping Hope Alive.

Learn more about Mitochondrial Failure and Chronic Fatigue Syndrome at Fighting Fatigue.

Arthritis Friend presents an episode of the medical show House which deals with chronic pain.  Finally some "cred" for what we cope with!

Back trouble from shoveling a late February snow?  Dean Moyer at The Back Pain Blog talks about What Causes Herniated Discs.

In Sickness and In Health writes about Facing Cancer as a Couple.

Can pain be a teacher?  Working With Chronic Illness explores What We Can Learn from Chronic Illness and Pain.

Chronic Illness Pain Support shares her experience of being diagnosed with a chronic illness in her 20's:  You're Too Young to be That Sick!

Friday, February 20, 2009

Results for "pain" at library search site lets you:

  • Search many libraries at once for an item and then locate it in a library nearby
  • Find books, music, and videos to check out
  • Find research articles and digital items (like audiobooks) that can be directly viewed or downloaded
  • Link to "Ask a Librarian" and other services at your library
  • Post your review of an item, or contribute factual information about it

Saturday, February 14, 2009

Music can take the pain away, study finds

Music may be the analgesic of the art world.

A recent study done at Glasgow Caledonian University found that people who were listening to their favourite music felt less pain and could stand pain for a longer period.

Pain researcher Laura Mitchell has measured how people respond to pain with various forms of distractions, including relaxing music, listening to humorous audio tapes, doing math puzzles and looking at art.

As she told CBC's Q cultural affairs show, music is the stimulus that most seems to keep people's minds off the pain.

"Favourite music has come out consistently, even to an extent that's really surprised me in designing these studies, as being extremely effective in how people can tolerate the pain and in actually reducing how much pain they feel," Mitchell said.

But not just any music — it's not the relaxing jazz playing in the dentist's office or the classical piped into the clinic waiting room that does people good, but their own personal favourite.

"I've done this now with about … 400 people and there doesn't seem to be anything in common between the pieces that they bring," Mitchell said.

"I've had Smashing Pumpkins to Kylie Minogue to Destiny's Child right through pop, old-fashioned rock right to techno-dance music that most people would find actually quite painful themselves."

In January, Mitchell published a study in the journal Psychology of Aesthetics, Creativity, and the Arts, showing the significant effects of music on pain.

She used a test that involves asking people to dunk their hand, up to the wrist, in frigid water, and keep it there as long as they can stand it. The test is only done on healthy people and there is an upper limit on the amount of time they keep their hand in the cold bath.

"We were looking to see whether music would have an effect on people's tolerance of pain — to how long they could tolerate some kind of painful stimulus and also whether it would reduce the actual feeling, their actual pain perception for them and whether it would reduce the anxiety of human pain and whether it would help them feel a bit of control over pain they're going through," she said.

People reported their ability to distract themselves from pain more than doubled if they were listening to their favourite music, while their perception of the amount of pain they felt fell significantly.

Mitchell, who's been studying art and pain management for eight years, believes it's the emotional associations of music that lessen human perception of pain.

"It's the distraction of music that you love and you have a relationship with. And you're so emotionally tied to it, you're so emotionally engaged, that it can actually take the pain away," she said.

One of her studies compared the effects of music to the effects of looking at a favourite work of art —test subjects were invited to choose a painting to look at from among 15 of the world's most popular artworks.

The art helped, when compared to looking at a blank wall, but listening to music was far more effective, she said.

Mitchell believes her research will make a difference in many medical situations — for example in dealing with chronic pain or for people facing painful medical tests.

"We want to give clinicians and health care professionals a means to make it more comfortable for patients. To take their minds off the scariness of being in hospital and the noise and people rushing about that can make you feel worse," she said.

Pain management has only recently been given the importance it deserves, Mitchell said.

"It's something that really, just in the last five years, become really really important," she said.

"In Europe now about one in five people suffer from chronic pain and they have it on average for seven years and two-thirds of them feel their medication just isn't enough to really give them the relief that they need."

Monday, February 09, 2009

The American Pain Society and the American Academy of Pain Publish Guidelines for Prescribing Opioids

The American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) has published the first comprehensive, evidence-based clinical practice guideline to assist clinicians in prescribing potent opioid pain medications for patients with chronic non-cancer pain. The guideline appears in the February issue of The Journal of Pain.

To create this guideline, researchers reviewed more than 8,000 published abstracts and nonpublished studies to assess clinical evidence on which the new recommendations are based.

"This guideline was a true multidisciplinary effort that sought to address in a balanced manner the many challenging issues that clinicians face with regard to when and how to prescribe opioids for chronic noncancer pain," said principal investigator Roger Chou, MD, Oregon Evidence-Based Practice Center, Oregon Health & Science University, Portland, Oregon.

"A key part of this process was performing a comprehensive literature review to inform the recommendations -- though an important take-home message is that even though the recommendations represent the best judgment of the panel based on the currently available literature, there is still a lot of research that needs to be done."

The expert panel concluded that opioid pain medications are safe and effective for carefully selected, well-monitored patients with chronic non-cancer pain. They made 25 specific recommendations and achieved unanimous consensus on nearly all.

Prior to initiating chronic opioid therapy, the guideline advises clinicians to determine if the pain can be treated with other medications. If opioids are appropriate, the clinician should conduct a thorough medical history and examination, and assess potential risk for substance abuse, misuse or addiction.

A key recommendation urges clinicians to continuously assess patients on chronic opioid therapy by monitoring pain intensity, level of functioning, and adherence to prescribed treatments. Periodic drug screens should be ordered for patients at risk for aberrant drug behaviour.

Other recommendations in the practice guideline include:
· Methadone: Use of methadone for pain management has increased dramatically but few trials have evaluated its benefits and harms for treatment of chronic non-cancer pain. Methadone, therefore, should be started at low doses and titrated slowly. Because of its long half-life and variable pharmacokinetics, the panel recommends methadone not be used to treat breakthrough pain or as an as-needed medication.
· Abusers: Chronic opioid therapy must be discontinued in patients known to be diverting their medication or in those engaging in serious aberrant behaviours.
· Breakthrough Pain: As-needed opioids can be prescribed based on initial and ongoing analysis of therapeutic benefit versus risk.
· High Doses: Patients who need high doses of opioids should be evaluated for adverse events on an ongoing basis, and clinicians should consider rotating pain medications when patients experience intolerable side effects or inadequate benefit despite appropriate dose increases.
· Pregnancy: Clinicians should counsel women about risks of opioids in pregnancy and encourage minimal or no use of chronic opioid therapy unless potential benefits outweigh risks.

AP IMPACT: Drugmakers' push boosts 'murky' ailment

Two drugmakers spent hundreds of millions of dollars last year to raise awareness of a murky illness, helping boost sales of pills recently approved as treatments and drowning out unresolved questions -- including whether it's a real disease at all.

Key components of the industry-funded buzz over the pain-and-fatigue ailment fibromyalgia are grants -- more than $6 million donated by drugmakers Eli Lilly and Pfizer in the first three quarters of 2008 -- to nonprofit groups for medical conferences and educational campaigns, an Associated Press analysis found.

That's more than they gave for more accepted ailments such as diabetes and Alzheimer's. Among grants tied to specific diseases, fibromyalgia ranked third for each company, behind only cancer and AIDS for Pfizer and cancer and depression for Lilly.

Fibromyalgia draws skepticism for several reasons. The cause is unknown. There are no tests to confirm a diagnosis. Many patients also fit the criteria for chronic fatigue syndrome and other pain ailments.

Experts don't doubt the patients are in pain. They differ on what to call it and how to treat it.

Many doctors and patients say the drugmakers are educating the medical establishment about a misunderstood illness, much as they did with depression in the 1980s. Those with fibromyalgia have often had to fight perceptions that they are hypochondriacs, or even faking their pain.

But critics say the companies are hyping fibromyalgia along with their treatments, and that the grantmaking is a textbook example of how drugmakers unduly influence doctors and patients.

"I think the purpose of most pharmaceutical company efforts is to do a little disease-mongering and to have people use their drugs," said Dr. Frederick Wolfe, who was lead author of the guidelines defining fibromyalgia in 1990 but has since become one of its leading skeptics.

Whatever the motive, the push has paid off. Between the first quarter of 2007 and the fourth quarter of 2008, sales rose from $395 million to $702 million for Pfizer's Lyrica, and $442 million to $721 million for Lilly's Cymbalta.

Cymbalta, an antidepressant, won Food and Drug Administration approval as a treatment for fibromyalgia in June. Lyrica, originally approved for epileptic seizures, was approved for fibromyalgia a year earlier.

Drugmakers respond to skepticism by pointing out that fibromyalgia is recognized by medical societies, including the American College of Rheumatology.

"I think what we're seeing here is just the evolution of greater awareness about a condition that has generally been neglected or poorly managed," said Steve Romano, a Pfizer vice president who oversees its neuroscience division. "And it's mainly being facilitated by the fact the FDA has now approved effective compounds."

The FDA approved the drugs because they've been shown to reduce pain in fibromyalgia patients, though it's not clear how. Some patients say the drugs can help, but the side effects include nausea, weight gain and drowsiness.

Helen Arellanes of Los Angeles was diagnosed with fibromyalgia in September 2007 and later left her job to go on disability. She takes five medications for pain, including Lyrica and Cymbalta.

"I call it my fibromyalgia fog, because I'm so medicated I go through the day feeling like I'm not really there," Arellanes said. "But if for some reason I miss a dose of medication, I'm in so much pain."

A single mother of three, Arellanes sometimes struggles to afford all her medications. She said she is grateful that a local Pfizer sales representative occasionally gives her free samples of Lyrica "to carry me through the month."

The drugmakers' grant-making is dwarfed by advertisement spending. Eli Lilly spent roughly $128.4 million in the first three quarters of 2008 on ads to promote Cymbalta, according to TNS Media Intelligence. Pfizer Inc. spent more than $125 million advertising Lyrica.

But some say the grants' influence goes much further than dollar figures suggest. Such efforts steer attention to diseases, influencing patients and doctors and making diagnosis more frequent, they say.

"The underlying purpose here is really marketing, and they do that by sponsoring symposia and hiring physicians to give lectures and prepare materials," said Wolfe, who directs the National Data Bank for Rheumatic Diseases in Wichita, Kan.

Similar criticisms have dogged drugmakers' marketing of medicines for overactive bladder and restless legs syndrome.

Many of the grants go to educational programs for doctors that feature seminars on the latest treatments and discoveries.

Pfizer says it has no control over which experts are invited to the conferences it sponsors. Skeptics such as Wolfe are occasionally asked to attend.

The drug industry's grants also help fill out the budgets of nonprofit disease advocacy groups, which pay for educational programs and patient outreach and also fund some research.

"If we have a situation where we don't have that funding, medical education is going to come to a screeching halt, and it will impact the kind of care that patients will get," said Lynne Matallana, president of the National Fibromyalgia Association.

Matallana founded the group in 1997 after she was diagnosed with fibromyalgia. A former advertising executive, Matallana said she visited 37 doctors before learning there was a name for the crushing pain she felt all over her body.

A decade later, her patient advocacy group is a $1.5 million-a-year operation that has successfully lobbied Congress for more research funding for fibromyalgia. Forty percent of the group's budget comes from corporate donations, such as the funds distributed by Pfizer and Eli Lilly.

Pfizer gave $2.2 million and Lilly gave $3.9 million in grants and donations related to fibromyalgia in the first three quarters of last year, the AP found. Those funds represented 4 percent of Pfizer's giving and about 9 percent of Eli Lilly's.

Eli Lilly, Pfizer and a handful of other companies began disclosing their grants only in the past two years, after coming under scrutiny from federal lawmakers.

The message in company TV commercials is clear. "Fibromyalgia is real," proclaimed one Lyrica ad. Researchers who've studied the condition for decades say it's not that simple.

Since the 1970s, Wolfe and a small group of specialists have debated the condition in the pages of medical journals. Depending on whom you ask, it is a disease, a syndrome, a set of symptoms or a behavior disorder.

The American College of Rheumatology estimates that between 6 million and 12 million people in the U.S. have fibromyalgia, more than 80 percent of them women. It's not clear how many cases are actually diagnosed, but Dr. Daniel Clauw of the University of Michigan said pharmaceutical industry market research shows roughly half are undiagnosed. People with fibromyalgia experience widespread muscle pain and other symptoms including fatigue, headache and depression.

After 30 years of studying the ailment, rheumatologist Dr. Don Goldenberg says fibromyalgia is still a "murky area."

"Doctors need labels and patients need labels," said Goldenberg, a professor of medicine at Tufts University. "In general, it's just more satisfying to tell people, 'You have X,' rather than, 'You have pain.'"

While Goldenberg continues to diagnose patients with fibromyalgia, some of his colleagues have stopped, saying the condition is a catchall covering a range of symptoms.

Dr. Nortin Hadler says telling people they have fibromyalgia can actually doom them to a life of suffering by reinforcing the idea that they have an incurable disease.

"It's been shown that if you are diagnosed with fibromyalgia, your chances for returning to a level of well-being that satisfies you are pretty dismal," said Hadler, a professor at the University of North Carolina, who has occasionally advised health insurers on how to deal with fibromyalgia.

Hadler said people labeled with fibromyalgia are indeed suffering, not from a medical disease but from a psychological condition. Instead of drugs, patients should receive therapy to help them "unlearn" their predicament, he said.

Research by the University of Michigan's Clauw suggests people with fibromyalgia experience pain differently because of abnormalities in their nervous system. Brain scans show unusual activity when the patients experience even minor pain, though there is no abnormality common to all.

Clauw's work, however, illustrates the knotty issues of drug company funding. He has done paid consulting work for the drugmakers, and he's received research funding from the National Fibromyalgia Research Association, which receives money from the drugmakers.

While Clauw acknowledges that Lyrica and Cymbalta do not work for everyone, he has little patience for experts who spend more time parsing definitions than helping patients.

"At the end of the day I don't care how you categorize this -- it's a legitimate condition and these people are suffering," Clauw said.;_ylt=AiuxqAdthFm3hOTarH_jfZfyKIkA

Sunday, February 08, 2009

Zen Meditation Alleviates Pain, Study Finds

Zen meditation – a centuries-old practice that can provide mental, physical and emotional balance – may reduce pain according to Université de Montréal researchers. A new study in the January edition of Psychosomatic Medicine reports that Zen meditators have lower pain sensitivity both in and out of a meditative state compared to non-meditators.

Joshua A. Grant, a doctoral student in the Department of Physiology, co-authored the paper with Pierre Rainville, a professor and researcher at the Université de Montréal and it's affiliated Institut Universitaire de Gériatrie de Montréal. The main goal of their study was to examine whether trained meditators perceived pain differently than non-meditators.

"While previous studies have shown that teaching chronic pain patients to meditate is beneficial, very few studies have looked at pain processing in healthy, highly trained meditators. This study was a first step in determining how or why meditation might influence pain perception." says Grant.

For this study, the scientists recruited 13 Zen meditators with a minimum of 1,000 hours of practice to undergo a pain test and contrasted their reaction with 13 non-meditators. Subjects included 10 women and 16 men between the ages of 22 to 56.

The administered pain test was simple: A thermal heat source, a computer controlled heating plate, was pressed against the calves of subjects intermittently at varying temperatures. Heat levels began at 43 degrees Celsius and went to a maximum of 53 degrees Celsius depending on each participant's sensitivity. While quite a few of the meditators tolerated the maximum temperature, all control subjects were well below 53 degrees Celsius.

Grant and Rainville noticed a marked difference in how their two test groups reacted to pain testing – Zen meditators had much lower pain sensitivity (even without meditating) compared to non-meditators. During the meditation-like conditions it appeared meditators further reduced their pain partly through slower breathing: 12 breaths per minute versus an average of 15 breaths for non-meditators.

"Slower breathing certainly coincided with reduced pain and may influence pain by keeping the body in a relaxed state." says Grant. "While previous studies have found that the emotional aspects of pain are influenced by meditation, we found that the sensation itself, as well as the emotional response, is different in meditators."

The ultimate result? Zen meditators experienced an 18 percent reduction in pain intensity. "If meditation can change the way someone feels pain, thereby reducing the amount of pain medication required for an ailment, that would be clearly beneficial," says Grant.

Wednesday, February 04, 2009

Respectful Insolence: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we?

I think my title says it all: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Can we?

The reason I ask this question is because yet another large meta-analysis has been released that is entirely consistent with the hypothesis that acupuncture is a placebo. Because I've written about so many of these sorts of studies over the last year or two that I really had a hard time mustering up the will to write about one more. But I got in pretty late last night and therefore knew I could handle this in a reasonably expeditious fashion. Besides, it is a fairly interesting study as far as methodology. Also, I've been on a roll writing about antivaccine nonsense, but it's taken a toll. My foray into the discussion forums resulted in a real assault on my neurons, so much so that, while I had considered taking on the not-so-dynamic duo, two crappy tastes that taste crappy together, otherwise known as David Kirby and Robert F. Kennedy, Jr. in the pages of The Huffington Post. Truly, just when I think HuffPo can't go any lower, damn if it doesn't prove me wrong. In any case, I thought it ill advisable to subject myself to more of Kirby and RFK, Jr. so soon on the heels of waves of burning mommy stupid. Better to take on this study, because it's yet another piece of evidence that backs up what I've come to accept after having actually read that acupuncture literature: That acupuncture is nothing more than a placebo.

So let's take a bit more of a look at the study. Entitled Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups appeared in the BMJ two days ago and was performed by Madsen et al at the Nordic Cochrane Center, meaning it's a Cochrane review.

A meta-analysis, as I hope you recall, is a systematic methodology for reviewing the peer-reviewed medical literature in which studies are examined and pooled together to try to produce a consensus. Of course, this is the sort of thing that's fraught with methodological problems. It's easy to wonder what pooling data means when the data come from multiple studies that may have variable inclusion criteria, different endpoints, different design. However, it can be done, although one should look at the results with a skeptical eye. After all, garbage in = garbage out, which means that study selection is almost always the most important aspect of any meta-analysis. Consequently, that's the part I always look at first.

This particular meta-analysis examined studies of acupuncture for pain. What's good about the search strategy used is that it not only discarded various types of acupuncture that aren't really acupuncture, such as electroacupuncture, but it also only included only trials that used some sort of placebo acupuncture, be it sticking needles into non-meridian points or using the special "placebo needles" that retract and give the illusion of penetrating the skin but do not actually do so. In other words, it used only trials that included an acupuncture group, a placebo acupuncture group, and a no acupuncture group. Another strength of the analysis is that it also included only studies in which both the acupuncture groups and the no-acupuncture groups were given the same medical interventions. If the no treatment group received a treatment substantially different from the acupuncture groups, the study was not included. Finally, trials in which the patients self-reported pain on a visual analog scale or similar pain scale were included.

The results were thirteen trials, with a total of 3,025 patients between them. Unfortunately, this leads me to mention one weakness of this analysis, namely that the studies included covered a rather wide range of conditions, including knee osteoarthritis,w7-w9 tension type headache, migraine, low back pain, fibromyalgia, abdominal scar pain, postoperative pain, and procedural pain during colonoscopy. Moreover, the duration of treatment varied from one day to 12 weeks. I could also complain about the way the term qi and meridians are described in the manuscript as though they had any validity other than as prescientific magical thinking, but what would be the point? Be that as it may, what were the findings?

In essence, zilch, nada, zip.

More ...

Acupuncture Offers Only Minimal Pain Relief - Placebo gets better results than acupuncture in some trials

Acupuncture offers some pain relief but at a level below clinical significance, according to a report published online Jan. 28 in BMJ.

Matias Vested Madsen, of the Nordic Cochrane Centre in Copenhagen, Denmark, and colleagues conducted a review of 13 trials comprising 3,025 patients who underwent acupuncture, placebo (sham) acupuncture, or no acupuncture in randomized trials to establish the pain relief effects of the therapy on pain caused by a range of conditions including knee osteoarthritis, migraine and low back pain.

Acupuncture resulted in a 4 mm reduction in pain levels on a 100 mm visual analogue scale, well below the 10 mm difference that is described as minimal or little change, and therefore of no clinical significance, the investigators found. There was a wide variation in results for placebo acupuncture, from a 24 mm change in some large trials to a clinically irrelevant 5 mm change in others, the researchers report.

"We suggest that future trials on acupuncture for pain focus on two strategies. Firstly, researchers could try to reduce bias by ensuring blinding when possible," the authors write. "Secondly, researchers could try to separate the effects involved: the physiological effect of needling at acupuncture sites or at other sites and the psychological effect of the treatment ritual or of the patient-provider interaction more broadly."