| Pain Center updated Friday, March 27, 2009
Ultimately, clinicians want to relieve 100% of their patients’ pain; however, false notions of addiction blind them to the fact that opioids are safe, effective analgesics that relieve pain almost completely.1 To understand how opioids are effective for intractable pain without threat of addiction, it is necessary to understand what addiction is. Addiction Defined Addiction is defined by the American Society of Addiction Medicine as the abuse of any psychoactive substance with compulsion and loss of control despite adverse consequences.11 The American Medical Association Task Force defines addiction as a chronic disorder characterized by the compulsive use of a substance resulting in physical, psychological, or social harm to the user and continued use despite the harm.11 In other words, addiction involves a dependence upon a drug to experience euphoria despite harm to oneself or others. Opioid use for intractable pain is not associated with dependency upon a drug despite harm to oneself.3 In fact, opioids increase intractable pain patients’ quality of life. Patients do become physically dependent upon opioids3 because, without appropriate opioid therapy, they would continue to feel pain. Also, according to Aaron Gilson, Researcher at the Pain and Policy Studies Group at the University of Wisconsin, initial tolerance to opioids may result and, if abruptly taken off opioid treatment, withdrawal symptoms may arise. However, as Gilson goes on to explain, tolerance and withdrawal symptoms resulting from opioid treatment for intractable pain do not indicate addiction. These are simply physiological reactions to opioids. Studies have shown that less than 1% of those taking appropriate levels of opioids for pain management become addicted.1,4 Difference between pain patients and addicts The difference between pain patients and addicts seeking euphoria is that patients can take increasing doses of opioids, as pain persists, without severe side effects while addicts cannot.4 As intractable pain continues to persist, usually a sign of disease progression, pain patients may require higher increments of opioids to relieve pain. Fortunately, opioids taken for intractable pain do not have a ceiling dosage—a dosage where the drug can no longer treat a higher level of pain.12 In fact, according to Dr. William Hurwitz, pain patients who would otherwise be incapacitated by pain can increase their quality of life by taking dosage levels of opioids that would kill the average person.4 Although not proven, researchers believe that pain patients and addicts respond to opioids differently because the nervous pathway that transports intractable pain develops little to no tolerance to opioids. The nervous pathways that transport acute pain and pleasure do develop significant tolerance to opioids.7 20% of people with Chronic Pain, seek no help.Newswise - A Rochester-based study has found more than 20 percent of people with chronic pain did not seek physician help for their pain. The study supports the opinion of many physicians that a large segment of patients has an unmet need for pain care. Increased media attention and physician education are recommended to decrease the number of "silent sufferers," according to the study. Published in the February issue of Mayo Clinic Proceedings, the study looked at 3,575 people. Of the 2,211 respondents who reported pain of more than three months' duration, 22.4 percent (497) stated that they had not informed their physician about their pain. The survey covered a cross-section of residents of Olmsted County, Minn., from March through June 2004. It is unclear whether the reasons for not seeking treatment are limited to minor impact of pain on the person, or for other reasons such as poor previous experiences with pain care, perceived lack of effective treatments, and barriers to health care; lack of medical insurance, for example. The importance of pain management has gained increasing recognition in the last decade. In 1995, the American Pain Society declared pain to be the fifth vital sign, a designation to increase pain awareness among health care professionals. The rapid increases in pain medicine prescription hint at a population of patients with unmet pain needs, according to the study. Barbara Yawn, M.D., an Olmsted Medical Center physician and an author of the study, says, "Identification of patients in pain is essential to successful pain care. Despite significant efforts, successful pain care clearly is not happening. Physicians have a responsibility to ask their patients about chronic pain." Pain's health impact on society is significant. Pain sufferers report that their pain interferes with their general activities and sleep. Approximately 25 percent of "silent sufferers," those not telling their physician about their pain, indicated at least moderate interference with both general activity and sleep. A larger proportion of vocal sufferers (43.2 percent) showed comparable levels of interference. In general, the location of the pain had little effect on whether the patients reported their pain. The study found that chronic pain suffers who do not seek treatment tend to be younger men whose pain has less impact on their usual activities. Other researchers included Emmeline Watkins, Ph.D., from the Department of Epidemiology at AstraZeneca, and Peter Wollan, Ph.D., from Olmsted Medical Center, and Joseph Melton, M.D., from Mayo Clinic. The study was supported by a grant from AstraZeneca. A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 75 years and has a circulation of 130,000 nationally and internationally. Articles are available online at http://www.mayoclinicproceedings.com. Return to Topics Coalition of Pain Experts Offers Guidance on Measures to Prevent Misuse and Abuse of Pain Medications; Calls for Treating Chronic Pain as a Chronic Disease The roundtable included representatives from primary care and specialty medicine, nursing, nurse practitioners, and physician assistants, as well as representatives from the American Academy of Pain Medicine, the American Pain Society, the American Chronic Pain Association, National Pain Foundation, the American Pain Foundation, and other leaders in the pain community. The goals were to review the barriers to diagnosis and treatment of acute and chronic pain in clinical and community settings; increase public awareness of the disparities in pain treatment based on gender, race, ethnicity, and age, and provide recommendations to enable clinicians to overcome these barriers; implement management strategies to provide adequate pain relief for a spectrum of patients, including those who may be at highest risk for medication misuse, abuse, and diversion; and discuss emerging technologies to deter misuse, abuse, and diversion of opioids. Roundtable participants began by delineating some of the current obstacles to meeting their goals, and then collaborated on possible solutions. One of the major obstacles, they argued, is the inconsistency of guidelines for the diagnosis and treatment of pain, which represent a number of individual organizations and pain societies. Therefore, reorganizing the organizations and societies in the pain community into a single united group could enhance cooperation and eliminate fragmented guidelines and treatment standards. Similarly, the lack of standardized procedures for patient assessments (which should include physical examination and functional evaluation before and during treatment) has led to a lack of outcomes data in pain medicine. Development of protocols for outcomes studies—particularly studies that look at the effects of pain and treatment of pain on function and quality of life—as well as the generation of “best practices” can help overcome these obstacles.. The medical community’s focus on global outcomes of treatment, rather than on patient-specific outcomes, is yet another obstacle to optimal treatment for pain. But by having patients actively involved in their management plan, healthcare providers can become more knowledgeable patient advocates with legislators, insurers, and other medical professionals. Because it is not possible to provide complete relief to all patients with pain, education about realistic treatment outcomes is key for both patients and healthcare providers. For example, by becoming active members of their treatment teams, patients may realize improved quality of life despite persistence of a certain level of pain. Opioids are not appropriate for all patients with pain—for example, those whose pain is mediated through inflammatory pathways, who are more effectively treated with anti-inflammatory drugs. Nor are opioids appropriate for patients who may misuse/abuse/divert these medications. However, this obstacle may be resolved by drugs in development that utilize novel tamper-resistant and abuse-deterrent technologies. Furthermore, physicians’ prescribing of opioids has become limited not only by their abuse potential but also by the increased possibility of litigation and changes in medical insurance and governmental policies. In the past 10 years, adolescents and young adults have escalated their abuse and non-medical use of opioids. In 2006, 10% of youths aged 12 to 17 were current illicit drug users, with 3% using prescription drugs nonmedically, and nearly 20% of young adults aged 18 to 25 used illicit drugs, with more than 6% using psychotherapeutics nonmedically. At the same time, many (or even most) parents remain largely unaware that their children may be abusing drugs. Roundtable
participants agreed that many of these obstacles to effective diagnosis and management of
pain could be resolved by making pain medicine a primary medical specialty. As a positive
first step, they said, a 2-year fellowship or 4-year residency program in pain medicine
should be established in the medical curriculum. Training for pain medicine specialists
would include all facets of pain management (for example, anesthesiology, physiatry,
psychiatry, rehabilitation). The benefits of this expertise in pain medicine could then be
extended by incorporating pain management principles into other programs, promoting
learning for nurse practitioners, physician assistants, and other allied health
professionals. Study suggests physician concerns over widely publicized prosecutions are disproportionate to actual numbers of legal and regulatory actions Lorell
R. LaBoube, Center for Practical Bioethics Drew
Carlson, Federation of State Medical Boards Angelita
Plemmer, National Association of Attorneys General September 9, 2008 Some doctors under treat pain partially out of an unrealistic fear of legal repercussions, causing many chronic-pain patients to continue to suffer even though effective pain medications may be available to help them. A new study in the September 9 issue of Pain Medicine shows that between 1998 and 2006, only a tiny number of U.S. doctors actually appear to have been prosecuted or administratively sanctioned for improperly prescribing powerful pain medications. Over this eight year span, best-available data and records indicate that only about one in 1,000 practicing physicians was tried or sanctioned for offenses of this type. Study findings include the following: 725 physicians were identified as having been prosecuted or sanctioned for such violations during the nine-year time frame, or only about 0.1% of nearly 700,000 practicing patient care physicians in the US. Most of the patient care doctors identified in such cases were primary care physicians rather than specialists in other fields, including pain medicine. Among the 725 physicians involved in these cases, only 25 were pain medicine specialists or self-identified as such. In contrast, General Practice/Family Medicine physicians accounted for 285. In 2005 and 2006, the Drug Enforcement Administration reports having investigated an average of only 4-5 doctors per state each year for possible criminal offenses connected with improper prescription or handling of pain medications. Compared with physicians in the national workforce, significantly more of the study physicians were male, aged 55 or over, and lacked board certifications The authors of the study say a balanced approach is required, one that will allow doctors to responsibly prescribe powerful pain medications without fear, while allowing enforcement agencies to continue preventing the diversion and misuse of regulated pain-controlling drugs. "This study is the most comprehensive and systematic attempt to gather information on the numbers and types of physicians who actually have been tried and convicted for offenses involving improper prescribing or handling of controlled-substance pain medications," said Myra Christopher, president and CEO of the Center for Practical Bioethics. The
study analyzes the numbers and types of cases and physicians involved, criminal and
administrative charges brought, and case outcomes and sanctions. It also examines the
characteristics of the small number of physicians who have been involved in such cases,
including medical specialty, age and medical school. Christopher said results of this research suggest that physician fear of regulatory scrutiny cannot be explained by the actual rates of prosecution or administrative review. Reasons for this fear are more complex than an objective assessment of risk would suggest, she said. "However, it is essential to address the problem, because this fear on the part of physicians can change prescribing behaviors and undermine the treatment of pain," said Christopher. "Physicians and law enforcement must resolve competing perceptions surrounding the need to treat patients for pain and the need to prevent the diversion of drugs for illicit purposes," said Christopher. "All sides must work to achieve a balance between aggressive pain treatment and legal/regulatory policies that support the greater needs of society." An estimated 70 million Americans suffer from chronic pain, resulting in more than 50 million lost workdays each year. Links: Authors and
Affiliations Founded in 1984, the Center for Practical Bioethics is an independent organization nationally recognized for its work in practical bioethics. More than a think tank, the Center puts theory into action to help people and organizations find real-world solutions to complex issues in health and healthcare. The Federation of State Medical Boards is a national not-for-profit organization representing the 70 medical boards of the United States and its territories, including 14 state boards of osteopathic medicine. Its mission is continual improvement in the quality, safety and integrity of health care through the development and promotion of high standards for physician licensure and practice. The National Association of Attorneys General (NAAG) was founded in 1907 to help Attorneys General fulfill the responsibilities of their office and to assist in the delivery of high quality legal services to the states and territorial jurisdictions. NAAG fosters an environment of "cooperative leadership," helping Attorneys General respond effectively individually and collectively - to emerging state and federal issues. Restoration of function: the missing link in pain medicine?Schofferman
J. SpineCare Medical Group, Daly City, California, USA. Patients
are taught that it is safe to exercise despite pain and that there is no risk of harm.
Graded exposure requires progressive activity and exercise that emphasizes training in
strength, flexibility range of motion, and endurance despite pain.
Who hasn't wished she could watch her brain at work and make changes to it, the way a painter steps back from a painting, studies it and decides to make the sky a different hue? If only we could spell-check our brain like a text, or reprogram it like a computer to eliminate glitches like pain, depression and learning disabilities. Would we one day become completely transparent to ourselves, and — fully conscious of consciousness — consciously create ourselves as we like? The glitch I'd like to program out of my brain is chronic pain. For the past 10 years, I have been suffering from an arthritic condition that causes chronic pain in my neck that radiates into the right side of my face and right shoulder and arm. Sometimes I picture the pain — soggy, moldy, dark or perhaps ashy, like those alarming pictures of smokers' lungs. Wherever the pain is located, it must look awful by now, after a decade of dominating my brain. I'd like to replace my forehead with a Plexiglas window, set up a camera and film my brain and (since this is my brain, I'm the director) redirect it. Cut. Those areas that are generating pain — cool it. Those areas that are supposed to be alleviating pain — hello? I need you! Down-regulate pain-perception circuitry, as scientists say. Up-regulate pain-modulation circuitry. Now. Recently, I had a glimpse of what that reprogramming would look like. I was lying on my back in a large white plastic f.M.R.I. machine that uses ingenious new software, peering up through 3-D goggles at a small screen. I was experiencing a clinical demonstration of a new technology — real-time functional neuroimaging — used in a Stanford University study, now in its second phase, that allows subjects to see their own brain activity while feeling pain and to try to change that brain activity to control their pain. Over six sessions, volunteers are being asked to try to increase and decrease their pain while watching the activation of a part of their brain involved in pain perception and modulation. This real-time imaging lets them assess how well they are succeeding. Dr. Sean Mackey, the study's senior investigator and the director of the Neuroimaging and Pain Lab at Stanford, explained that the results of the study's first phase, which were recently published in the prestigious Proceedings of the National Academy of Sciences, showed that while looking at the brain, subjects can learn to control its activation in a way that regulates their pain. While this may be likened to biofeedback, traditional biofeedback provides indirect measures of brain activity through information about heart rate, skin temperature and other autonomic functions, or even EEG waves. Mackey's approach allows subjects to interact with the brain itself. "It is the mind-body problem — right there on the screen," one of Mackey's collaborators, Christopher deCharms, a neurophysiologist and a principal investigator of the study, told me later. "We are doing something that people have wanted to do for thousands of years. Descartes said, 'I think, therefore I am.' Now we're watching that process as it unfolds." Suddenly, the machine made a deep rattling sound, and an image flickered before me: my brain. I am looking at my own brain, as it thinks my own thoughts, including these thoughts. How does it work? I want to ask. Just as people were once puzzled by Freud's talking cure (how does describing problems solve them?), the Stanford study makes us wonder: How can one part of our brain control another by looking at it? Who is the "me" controlling my brain, then? It seems to deepen the mind-body problem, widening the old Cartesian divide by splitting the self into subject and agent. But most of all I want to know: Will I be able to learn it? For most of history, the idea of watching the mind at work was as fantastical as documenting a ghost. You could break into the haunted house — slice the brain open — but all you would find would be the house itself, the brain's architecture, not its invisible occupant. Photographing it with X-rays resulted only in pictures of the shell of the house, the skull. The invention of the CT scan and magnetic resonance imaging (M.R.I.) were great advances because they reveal tissue as well as bones — the wallpaper as well as the walls — but the ghost still didn't show up. Consciousness remained elusive. A newer form of M.R.I., functional magnetic resonance imaging (f.M.R.I.), used with increasingly sophisticated software, is accomplishing this, taking "movies" of brain activity. Researchers are able to watch the brain work, as the films show parts of the brain becoming active under various stimuli by detecting areas of increased blood flow connected with the faster firing of nerve cells. These films are difficult to read; researchers puzzle over the new images like Columbus staring at the gray shoreline, thinking, India? Most of the brain is uncharted, the nature of the terrain unclear. But the voyage has been made; the technology exists. Pain — a complex perception occupying the elusive space spanning sensation, emotion and cognition — is a particularly promising area of imaging research because, researchers say, it has the potential to make great progress in a short time. Perhaps more than any other aspect of human existence, persistent pain is experienced as something we cannot control but desperately wish we could. Acute pain serves the evolutionary function of warning us of tissue damage, but chronic pain does nothing except undo us. Pain is the primary complaint that sends people to the doctor. Of the 50-odd million sufferers in the United States, half cannot get adequate relief from their chronic pain. Many do not even have a diagnosis. Unlike acute pain, chronic pain is now thought to be a disease of the central nervous system that may or may not correlate with any tissue damage but involves an errant reprogramming in the brain and spinal cord. The brain can generate terrible pain in a wound that is long healed, in a body that is numb and paralyzed or — in the case of phantom-limb pain — in a limb that no longer even exists. Although there have been many theories about how pain works in the brain, it is only through neuroimaging that the process has actually been observed. It is now clear that there is no single pain center in the brain. Rather, pain is a complex, adaptive network involving 5 to 10 areas of the brain transmitting information back and forth. This network has two pain systems: pain perception and pain modulation, which involve both overlapping and distinct brain structures. The pain-modulatory system constantly interacts with the pain-perception system, inhibiting its activity. Much chronic pain is thought to involve either an overactive pain-perception circuit or an underactive pain-modulation circuit. Like everyone who suffers from chronic pain, I find it hard to believe that I have a pain-modulation circuit. The aspect of my pain I feel most certain about is that it is not voluntary: I cannot modulate it. And this belief is reinforced every single day that I suffer from pain, which is every day. Yet I know that pain is not a fact, like a broken bone; it's a perception, like hunger, about a physical state ("an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage," as the International Association for the Study of Pain defines it). And it's a mercurial perception; under certain circumstances the pain-modulatory system works like a spell and the brain completely blocks out pain. Soldiers, athletes, martyrs and pilgrims engage in battles, athletic feats or acts of devotion without being distracted by the pain of injuries. When the teenage surfer Bethany Hamilton's arm was bitten off by a shark, she felt pressure, but "I didn't feel any pain — I'm really lucky, because if I felt pain, things might not have gone as well," she said (articulating one reason the modulatory system evolved: if she had thrashed about in pain, she would have bled until she drowned). In addition to being activated by stress, the pain-modulatory system is triggered by belief. The brain will shut down pain if it believes it has been given pain relief, even when it hasn't (the placebo effect), and it will augment pain if it believes you are being hurt, even if you aren't (the nocebo effect). The brain's modulatory system relies on endogenous endorphins, its own opiatelike substances. The nature of a placebo has long been a source of speculation and debate, but neuroimaging studies have shown the way a placebo actually helps to activate the pain-modulatory system. In a recently published study led by Dr. Jon-Kar Zubieta at the University of Michigan Medical School, the brains of 14 men were imaged after a stinging saltwater solution was injected into their jaws. They were then each given a placebo and told that it would positively relieve their pain. The men immediately felt better — and the screen showed how. Parts of the brain that release endogenous opiates lighted up. In other words, fake opiates caused the brain to dispense real ones. Like some New Age dictum, philosophy becomes chemistry; believing becomes reality; the mind unites with the body. Other studies have shown that opiates and other medications rely on a placebo to achieve part of their effect. When subjects are covertly given strong opiates like morphine, they don't work nearly as well as they do if the subjects are told they are being given a powerful pain reliever. Even real medications require some of the brain's own bounty. Conversely, thinking about pain creates pain. In studies at Oxford University, Irene Tracey has shown that asking subjects to think about their chronic pain, for example, increases activation in their pain-perception circuits. Distraction, on the other hand, is a great analgesic; when Tracey's volunteers were asked to engage in a complicated counting task while being subjected to a painful heat stimulus, she could watch the pain-perception matrix decrease while cognitive parts of the brain involved in counting lighted up. At McGill University, Catherine Bushnell has shown that simply listening to tones while being subjected to a heat stimulus decreased activity in the pain-perception circuit. "There is an interesting irony to pain," comments Christopher deCharms, who worked with Mackey designing and carrying out the Stanford study. We were talking in his office at Omneuron, a Menlo Park medical-technology company he founded three years ago to develop clinical applications of neuroimaging. "Everyone is born with a system designed to turn off pain. There isn't an obvious mechanism to turn off other diseases like Parkinson's. With pain, the system is there, but we don't have control over the dial." The goal of the Stanford technique is to teach people to control their dials — to activate their modulatory systems without requiring the extreme stress of fleeing from a shark or the deception of a placebo. The hope of neuroimaging therapy (as deCharms calls the Stanford technique) is that repeated practice will strengthen and eventually change the ineffective modulatory system to eliminate chronic pain, the way long-term physical therapy can change muscular weakness. The scan would thus be more than a research tool: the scan itself would be the treatment, and the subject his or her own researcher. Only once do I recall having a glimmer of my own pain-modulatory system at work: a hidden power that emerged, dispensed with pain and then returned to some forgotten fold in my brain, where I have never been able to locate it again. The event did not take place on a battlefield or a marathon course or in a temple; it was in a basement of the Stanford University medical center three years ago. At the time, Mackey had designed an earlier study that did not use imaging technology but focused on how suggestion alters pain perception. Although I was not formally enrolled in the study, I asked if I could undergo a clinical demonstration. My experience illustrated the power of suggestion in an unexpected fashion. A metal probe attached to the underbelly of my arm heated up and cooled down at set intervals. I was told that although the heat probe would feel uncomfortable, my skin would not be burned. During one exposure, I was instructed to think of the pain as positively as possible, during another to think of it as negatively. After each sequence, I was asked to rate my pain on a 0-to-10 scale, with 10 being the worst pain I could imagine. Although I discovered that I could make the pain fluctuate depending on whether I was imagining that I was sunbathing or was the victim of an inquisition, I still rated all the pain as low — ranging from a 1 to a 3. If 10 was being slowly burned alive, I felt I should at least be begging for mercy to justify a rating of 5. So I insisted that Mackey turn up the dial so I could get a real response. But even during the moments when I was actively trying to imagine the pain as negatively as possible, it remained in a mental box of "not even burned," which kept it from really hurting: hurting, that is, the way a burn would. As it turned out, I got a second-degree burn that later darkened into a square mark. Mackey was more than a little dismayed as we watched the reddening skin pucker, but I was thrilled. Naturally the protocol had been carefully designed not to injure anyone, yet in my case that protection had failed because of the very phenomenon it was designed to study: expectation — the effect of the mind on pain or placebo. I had recently spent several weeks observing Mackey in the university's pain clinic, where he is associate director. I was so convinced that Mackey — then a tall sandy-haired 39-year-old with a deep interest in technology (he got a Ph.D. in electrical engineering before he went to medical school) and an air of radiant integrity — would not burn me that my brain had not perceived the stimulus as a threat and generated pain. I admired him, I trusted him, I was positive that he wouldn't hurt me. And, ipso facto, he hadn't. Mackey's genius as a practitioner, I thought, lay partly in his ability to similarly inspire patients. "When I started working with pain patients, I realized how much of the treatment involved trying to reverse learned helplessness," he said — to rally them out of the despair ingrained from years of unremitting pain and cajole their minds to chip in its own analgesic to their therapies. "The purpose of this study is to show patients their mind matters," Mackey said. The mark of the burn is barely visible now, but for a couple of years afterward, at times when my chronic pain was making me miserable, the sight of it would both encourage and reproach me. Here is the ultimate proof that my mind can control pain, I would think, yet I didn't know how to make it wake up and do so. I could take the edge off the pain by conjuring positive images, but the effects didn't last, and I never again had the remarkable placebo response that masked a second-degree burn. In fact, a mild burn from spilling tea on my hand one day brought tears to my eyes. When the real-time neuroimaging study began, I couldn't wait to try it. The area of the brain that the scanner focuses on is the rostral anterior cingulate cortex (rACC). The rACC (a quarter-size patch in the middle-front of the brain, the cingular cortex) plays a critical role in the awareness of the nastiness of pain: the feeling of dislike for it, a loathing so intense that you are immediately compelled to try to make it stop. Indeed, the pain of pain, you might say, its defining element, is the way in which the sensation is suffused with a particular unpleasantness researchers refer to as dysphoria. Since pain is a perception, it's not pain if you don't experience it as hurting. You can feel hot or cold or pressure, and note them simply as stimuli, but when they exceed a certain intensity, the rACC kicks in, and suddenly they become painful, riveting your attention and causing you to recoil. Many pain-reducing techniques aim to manipulate the conscious awareness of pain. Distraction, placebo, meditation, imagining pleasant scenes and hypnosis all result in a reduction of rACC activation when they work. Patients who have undergone a radical surgical treatment occasionally used for pain (as well as for mental illness) called a cingulotomy, in which the rACC is partly destroyed, report that they are still aware of pain but that they don't "mind" it anymore. Their emotional response has receded. The image I saw while lying in the f.M.R.I. machine at the time of the recent Stanford study was not literally my rACC but a visual analogue of it that is easier to see: a 3-D image of a fire. The flames represent the degree of activation in your rACC: when it is low, the flames are low; when rACC activation is high, the flames flare. The study involves five 13-minute scanning runs, each consisting of five cycles of a 30-second rest followed by a 1-minute interval in which you try to increase rACC activation and then a 1-minute interval in which you try to decrease rACC activation. Before my scan began, I was prepped in different mental strategies for increasing and modulating my pain. Everyone's brain works a bit differently, though, so subjects have to experiment in the scanner to see what is most effective for them. For some, trying to distract themselves from their pain works best; for others, focusing on their pain — like embracing a Zen koan — seems to be what triggers their pain-modulatory system. When deCharms used neuroimaging therapy on himself to try to alleviate his chronic neck pain, he concentrated on the pain itself and felt it "suddenly melt away." He said that a patient described the feeling as being "like a runner's high" (a state that has been shown to involve the release of endogenous endorphins). Increase Your Pain, the screen commanded, as the first run began. I tried to recall the mental strategies in which I had been prepped for increasing pain: Dwell on how hopeless, depressed or lonely you felt when your pain was most severe. Sense that the pain is causing long-term damage. Dwelling on the hopeless loneliness of my pain certainly made the flames of my rACC spark. The mental image that I found increased my pain the most, however, was the one that matched the visual analogue of the rACC: Picture a hot flame on your painful area. Try to make the flame grow in the painful area, and imagine it actually burning your flesh. Having recently read Ariel Glucklich's extraordinary "Sacred Pain," I had plenty of details of the burning of heretics and witches available to me. I had only to imagine the smell of sizzling hair to make the flames of my rACC explode. Decrease Pain, the screen commanded. The suggested pain-reduction strategies, however, did little to quell the flames on the screen. I pictured suffocating the pain with banal positive imagery: flowing water or honey, something soft and gentle, but my mind kept slipping back to the progress of the auto-da-fé, and the rACC fire flared. Feel that sensation, but tell yourself that it is just a completely harmless, short-term tactile sensation. Pilgrims and devotees all around the world choose to inflict pain upon themselves during sacred rites — from being nailed to crosses to dangling from hooks. For them, pain is an occasion for euphoria, not dysphoria. There are many historical records of the equanimity saints and martyrs often possessed during torture. The second-century Jewish martyr Rabbi Akiva, for example, continued to recite a prayer with a smile on his lips while the flesh was being combed from his bones. "All my life," he explained to the puzzled Roman general orchestrating his execution, "when I said the words 'You shall love the Lord your God with all your heart, with all your soul, and with all your might,' I was saddened, for I thought, When shall I be able to fulfill this command? Now that I am giving my life and my resolution remains firm, should I not smile?" As Glucklich writes, the conviction that pain is a spiritual opportunity seems paradoxically anesthetizing — or, as a scientist would say, religious states of conviction can robustly activate the pain-modulatory system. During my next Decrease Pain interval, instead of trying to picture a vacation, I imagined myself as a martyr, lucidly reciting Though I walk through the valley of the shadow of death while being burned at the stake. My rACC activation — I noted — respectfully quieted. Then I remembered that the 23rd Psalm seems to have Christian associations, and since I was presumably being tortured for being half-Jewish, a Jewish prayer might be more appropriate. Unless, that is, I was being accused of witchcraft, in which case, I might be generally disillusioned with Judeo-Christian prayer. As I tried to settle on a fantasy, I noticed that my rACC stayed low: Irene Tracey's theory of the modulating effects of distraction. By the last run, I had the strategies down — heretic-martyr: rACC down; heretic-victim: rACC up. The results of the scan, Mackey showed me, revealed significant brain control. A week later, I was scanned again, this time in the offices of Omneuron. I could feel that it was easier to control my rACC with less reliance on elaborate fantasy; I was interacting more directly with my brain. This learning effect was clearly seen in the recent Stanford study (which was financed in part by the National Institutes of Health). The first phase of the study looked at 12 subjects with chronic pain and 36 healthy subjects. (The healthy participants were subjected to a painful heat stimulus in the scanner and tried to modulate their responses. The chronic-pain patients, however, simply worked to reduce their own pain.) The chronic-pain patients who underwent neuroimaging training reported an average decrease of 64 percent in pain rating by the end of the study. (Healthy subjects also reported a significant increase in their ability to control the pain.) "One big concern we had," Mackey says, "is, Were we creating the world's most expensive placebo?" To ensure against that, Mackey trained a control group in pain-reduction techniques without using the scanner (as in his previous study) to see if that was as effective as employing a $2 million machine. Mackey also tried scanning subjects without showing them their brain images or tricking subjects by feeding them images of irrelevant parts of the brain or feeding them someone else's brain images. "None of these worked," Mackey says, "or worked nearly as well." Traditional biofeedback also compared unfavorably; changes in pain ratings of subjects in the experimental group were three times as large as in the biofeedback control group. The second phase of the study, which is now under way, is designed to assess whether neuroimaging therapy offers long-term practical benefits to a larger group of chronic-pain patients. After the six sessions designed to teach them to regulate their pain, they will be observed for at least six months. The idea is to see whether they can fundamentally change their modulation system so that it can reduce pain all the time without constantly and consciously thinking about it. If so, the technique would not simply provide shelter from the storm of pain; it would bring about climate change. "I believe the technique may make lasting changes because the brain is a machine designed to learn," deCharms says. The brain is soft-wired (plastic) rather than hard-wired: whenever you learn something new, new neural connections are believed to form and old, unused ones to wither away. (Researchers refer to this as activity-dependent neuroplasticity.) In other words, if you actively engage a certain brain region, you can alter it. Many diseases of the central nervous system involve inappropriate levels of activation in particular brain regions that change the way they operate (negative neuroplasticity). Some regions experience atrophy, while other regions become hyperactive. (For example, epilepsy involves hyperactivity of cells; stroke, Parkinson's and other diseases involve the atrophy of nerve cells.) With chronic pain, it is believed that additional nerve cells, recruited for transmitting pain, create more pain pathways in the nervous system, while nerve cells that normally inhibit or slow the signaling, decrease or change function. In addition, chronic pain results in a significant loss of other kinds of brain cells. A. Vania Apkarian at Northwestern University found that while the brain of a healthy person shrinks 2.5 percent a year, in a person with chronic back pain, it shrinks an additional 1.3 percent annually in the areas that involve rational thinking. I know chronic pain interferes with my concentration at times, but I never imagined that it could be truly impairing it! The Stanford technique may mitigate this harm by teaching people how to increase the efficacy of the healthy cells. Moreover, the technique may offer a particular advantage over drug therapy. It is very difficult to design drugs to fix a problem in a specific region of the brain because the receptors that drugs target, like the opiate receptors, generally appear in multiple systems throughout the brain (which is partly why drugs almost always have side-effects). Neuroimaging therapy, on the other hand, is designed to teach control of a localized brain region. "The technique gives people a tool they didn't know they had," Mackey says, "cognitive control over neuroplasticity. We don't fully understand how this feedback mechanism is working, but it provides tangible evidence that people can change something in their own brains, which can be very empowering. It takes Buddhist monks 30 years of sitting on a mountain learning to control their brains through meditation — we're trying to jump-start that process." As to how exactly it works — how the decision-making parts of the brain (the prefrontal regions of the cortex) cause the change in the rACC — "Heck if I know!" he says. "How do we get the brain to do anything? We can map out the anatomical circuits involved and the general functions of those circuits, but we can't tell you the mechanism by which any cognitive decision is translated into action." If neuroimaging therapy could treat pain, could it rewire the brain to fix other diseases, like depression, stroke and learning disabilities, or exercise the brain in ways that would make it cleverer and more adept at certain skills? Neuroimaging has shown, for example, that the part of the brains of London cabdrivers that regulates spatial relations is larger than usual and that learning to juggle creates visible changes in parts of the brain involved with motor coordination during three months of training. I'm constantly getting lost and dropping things. Could I exercise and strengthen those areas more quickly by, say, thinking about maps in the scanner than by driving around London? "What is the limit to neuroimaging therapy?" deCharms muses. "Could you learn to target the reward or serotonin system and up-regulate happiness? Could you augment psychotherapy by allowing the patient and the therapist to watch the brain?" — an idea Omneuron is already exploring, by bringing therapists and patients to the scanner and imaging patients' brains as they undergo the sessions. "After all, talk therapy is about learning to understand thought processes — to understand neural substrates and change them," he says. How deep can the insights that functional imaging might offer really go? What I'd like to do most is not fix problems or improve skills but use imaging as a vehicle for self-transparency. Instead of puzzling about my motivations, I'd like to be able to read my mind completely, like a book: for imaging to be the Plexiglas window through which I could finally see the ghost. "Hmm," Dr. Scott Fishman, chief of the pain-medicine division at the University of California, Davis, said dubiously when I brought up this notion. "I'm not sure that functional imaging is actually looking at the mind. The mind is like a virtual organ — it doesn't have a physical address that we know about. Functional imaging provides a two-dimensional snapshot of a three-dimensional or a four-dimensional event of this entity of the mind. Right now, imaging is just looking at the brain; we have to be honest about that." Imaging shows the level of activation of different parts of the brain, from which we can extrapolate something about the mind, he points out, "but what we really need to see is how the parts talk to each other — and the complex nuances of their language." The brain has more than a hundred billion neurons. All functional imaging can tell us now is that a few hundred million of them in various areas become more active at certain times. It's as if you were trying to conduct a symphony by watching a silent film of the concert. You would see the players in the bass section active at one moment, vigorously gesturing, and then the rest of the orchestra would join in, but you couldn't hear the notes or how they form strands of melody and harmony and meld together to create the ethereal experience. "Consciousness is not neurons firing — consciousness is a transcendent emergent phenomenon that depends on the firing of neurons," says Dr. Daniel Carr, an eminent pain researcher who is now the C.E.O. of Javelin Pharmaceuticals. "The gears of a watch rotate and keep time, but the turning of the gears is not time. The question is, Is neuroimaging a picture of the experience of consciousness or is it a picture of a mechanism associated with that experience? Can there actually be a picture of an experience? Does a picture of a funeral or a wedding show you experiences? Or is there an unbridgeable gap there because you need to already understand the experience in order to interpret the photos? If a higher being told us how consciousness works, could we understand the explanation?" Chronic Pain and Depression Deserve Separate Treatment (Ivanhoe Newswire) -- People who suffer from both chronic pain and depression often go home from the doctor with a prescription to treat just their depression. However, that’s not good enough for many of them, report investigators who studied patients with both conditions. While pain and depression often do go hand-in-hand, researchers found pain is an independent factor and deserves to be treated on its own. The researchers used magnetic resonance imaging (MRI) to measure the response to pain in 53 people with fibromyalgia -- a condition causing tenderness, stiffness and fatigue. They also interviewed the patients about depressive symptoms and had them complete standard questionnaires aimed at diagnosing their level of depression. Results showed the patients reacted similarly to the application of pressure to their thumbnails in areas of the brain responsible for the identification of pain, regardless of their depression diagnosis. Conversely, areas of the brain associated with depression were affected differently depending on the person’s level of depression. “Much has been made of the overlap and similarities between pain and symptoms of depression, but these and other data suggest it is also important to identify pain-processing mechanisms that are independent of mood,” write the authors. They believe patients suffering from pain and depression should receive appropriate treatment for both conditions. This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week. To subscribe, go to: http://www.ivanhoe.com/newsalert/. SOURCE: Arthritis & Rheumatism, 2005;52:1577-1584 Return to TopicsImmune-to-brain
communication dynamically modulates pain: Physiological However,
glially driven pain can also occur under pathological conditions, such as occurs following
peripheral nerve Focus on Pain (Travell) Seminar Orlando, 2003 (notes
by Devin J. Starlanyl) Attitudes toward opioid use for chronic pain: Pain
Res Manag. 2003 Winter;8(4):189-94. Morley-Forster PK, Clark AJ, Speechley M, Moulin DE. New Textbook Teaches Pain Management September 8, 2003 05:07 PM EDT WASHINGTON - An estimated 50 million Americans suffer from persistent pain, yet most medical students have no courses focused on treating pain, according to the American Academy of Pain Medicine. "Untreated pain, tragically, is an epidemic in the United States," Dr. Louis Sullivan, former Health and Human Services secretary, said Monday as he announced an initiative to promote education on pain management at the country's medical schools. The American Academy of Pain Medicine has developed a Web-based textbook that will be available to medical students without charge beginning September 2004. It covers the neurobiology of pain, patient evaluation and common types of pain, such as cancer and pediatric pain, and includes self-tests. The project is financed by a grant from the Purdue Pharma Fund, a branch of the drug company that makes the painkiller OxyContin. Dr. Daniel Carr, director of the project and a professor of pain research at Boston's New England Medical Center, said the textbook focuses on medical and behavioral treatments for pain, because they are backed by more research than alternative therapies such as acupuncture. Only 3 percent of medical schools require students to take a course on pain management, according to a survey of 125 schools by the Association of American Medical Colleges in 2000 and 2001. Developed with the participation of the Association of American Medical Colleges, the new textbook will be tested in he coming months at the Morehouse School of Medicine, in Atlanta; the University of Connecticut School of Medicine, in Farmington, Conn.; and the Texas College of Osteopathic Medicine, in Fort Worth, Texas. While millions of Americans suffer from pain in silence, the abuse of prescription drugs is well documented. Nearly 3 million young people, age 12 to 17, said they had used prescription drugs for nonmedical reasons at least once, according to a January 2003 government report. OxyContin, a brand name for the drug oxycodone, is among the most-abused prescription medications. Nevertheless, project director Carr said, "The burden of undertreated pain dwarfs overtreated pain" in the overall society. American Academy of Pain Medicine: http://www.painmed.org Does chronic pain predict future psychological distress? A
population based survey of 1953 individuals identified subjects' psychological status and
whether they To
examine our main hypothesis a final analysis was undertaken adjusting this association for
those co-morbid features assessed at baseline. Following these adjustments chronic
widespread pain was no longer significantly associated with future distress (OR=1.5, 95%
CI (0.8,2.9)). Chronic widespread pain was associated with Modern nerve stimulators to kill pain 336666666666666666666666666666 The epidemiology of chronic generalized musculoskeletal pain. Researchers find gene involved in pain relief Evidence of involvement of central neural
mechanisms in generating Weather and the pain in fibromyalgia: are they related?
Sleep and chronic pain. Challenges to the alpha-EEG sleep pattern as a pain
specific sleep anomaly OBJECTIVE: The alpha-EEG sleep anomaly has been associated with chronic benign pain syndromes. Although controversial, the anomaly is believed by some to be an important biologic correlate of certain otherwise poorly explained painful conditions (e.g., fibromyalgia and chronic fatigue syndrome). To shed further light on this phenomenon, this study compared the sleep and psychological characteristics of chronic pain patients who exhibited the alpha-EEG sleep anomaly with pain-free psychiatric and medical patients who also were found to exhibit the alpha-EEG anomaly. METHODS: The alpha-EEG sleep was identified in the polysomnographic records of 5% of over 1000 consecutive sleep patients. Objective sleep parameters, daytime sleepiness and psychological characteristics (Minnesota Multiphasic Personality Inventory [MMPI] scores) of patients exhibiting this anomaly were examined. RESULTS: The alpha-EEG anomaly was identified in only 5% of the total patient sample. Patients with the alpha-EEG anomaly could be further classified into three diagnostic subgroups: chronic pain, psychiatric and other medical/sleep disorders, The subgroups were compared on sleep parameters and psychological characteristics. Less than 40% of the patients exhibiting the alpha-EEG anomaly experienced chronic pain. Chronic pain patients evidenced disturbed sleep patterns and psychological characteristics that were for the most part similar to those observed1000 in some pain-free medical and psychiatric patients. Only the medical subgroup exhibited objective daytime sleepiness. The alpha-EEG sleep disturbance was not accounted for by psychological characteristics. CONCLUSIONS: These findings challenge the notion that alpha-EEG sleep is of direct etiological significance in producing the pain complaint among patients with chronic pain since the alpha-EEG sleep was not a sufficient condition for pain. Chronic pain and difficulty in relaxing postural
muscles in patients with fibromyalgia and chronic whiplash associated disorders.1:
J Rheumatol 2001 Jun;28(6):1361-8 Pain Research Comes into Its Own Molecular biology may provide answers to relief "Previously,
scientists generally believed that glia played no role in pain because they lack axons and
therefore were incapable of cell-to-cell signaling. But now, some researchers believe that
glial activation can create, maintain, or expand pain in response to peripheral injury and How to find relief from the pain that wont go away By Winnie Yu Twenty years ago, Julie Lydon of Norwood, Massachusetts, started to experience lower back pain. Soon she couldn’t stand up straight, and her muscles stiffened when she sat for too long. Her body throbbed, and she was tired all the time. Doctors ran a battery of tests, looking for cancer, leukemia, anything. Finally, after 15 long years, Julie had a diagnosis: fibromyalgia. This chronic disorder, marked by unending pain and fatigue, affects up to 10 million Americans, the majority of whom are women. But many patients have a hard time getting diagnosed since the exact causes of fibromyalgia are unclear, there is no blood test available and symptoms can vary widely. As scientists continue to study this mysterious ailment, promising discoveries are being made to help patients with fibromyalgia better understand and manage their condition. New
studies, new Discoveries Other
findings could explain the intense pain that patients feel. Fibromyalgia patients have
higher than normal levels of the neural hormone substance P. This hormone, found in spinal
fluid, sends pain signals after an injury. At the same time, people with fibromyalgia have
lower levels of serotonin, a neurotransmitter that reduces pain. Studies suggest that genes may also play a role. “Now that we’ve started to map the human genome, research suggests that there may be twenty genes or more that could be responsible for fibromyalgia,” says Kim Jones, Ph.D., R.N., assistant professor at the Oregon Health & Science University in Portland and a fibromyalgia researcher. “People with a greater number of potentially affected genes may require little or no environmental stimulation to turn on their fibromyalgia genes. Others may need more stimuli.” Among the environmental factors under investigation by the Arthritis Foundation are physical trauma, viral or bacterial infections and emotional distress. Drug
Companies Look Ahead Diet
Makes a Difference Eating a balanced diet will help support the immune system, says Leslie Bonci, R.D., a spokeswoman for the American Dietetic Association and director of sports nutrition at the University of Pittsburgh Medical Center. That means getting enough protein, essential fatty acids, antioxidants and vitamins A, C and E. Foods such as tuna, chicken, yogurt and peanut butter are good sources of protein. Fresh fruits and vegetables, dried fruits and frozen veggies are all good sources of antioxidants and vitamins A, C and E. And essential fatty acids, such as omega-3s, are found in fatty fish, such as tuna and salmon, as well as in ground flaxseed. The
Age-Old Remedy: Exercise Andrea Whitaker, 46, of Cambridge, Massachusetts, agrees. “The worst thing I can do is not move,” says Andrea, who was diagnosed with fibromyalgia six years ago. “Staying immobile is a definite trigger. My muscles just freeze up.” According to Don L. Goldenberg, M.D., medical advisor for the Arthritis Foundation, a patient should focus most on cardiovascular workouts such as walking or water aerobics. Besides improving general fitness, cardiovascular exercise improves immunity and elevates mood, he says. Stretching is also important. The intense pain of the disease tightens muscles, causing them to shorten and lose range of motion. “Stretching is critical for preventing muscle injury,” says Robert Bennett, M.D., professor of medicine at the Oregon Health & Science University and a longtime researcher in the field. “Ideally, you should gently stretch each muscle group twice a day for about four to five minutes.” Strength training also plays a role. A study by Drs. Bennett and Jones found that specially tailored twice-weekly strength-training classes paid off even more than flexibility training did. Jane Walpole has known this for years. In 1989, the 50-year-old from Tigard, Oregon, developed fibromyalgia so severe she abandoned her career as a dentist and gave up kayaking and skiing. Several years later, while caring for her premature niece, Jane found herself constantly lifting the 4 1/2-pound infant. It was painful at first, but she persevered. As the baby gained weight, Jane grew stronger. Now she lifts free weights two or three times a week. “Exercise and weight lifting relieve pain. You just have to take it slow and listen to your body,” she says. Slow
Down and Breathe The
Rx Factor To prevent inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and naproxen (Aleve), and cox-2 inhibitors such as celecoxib (Celebrex) and rofecoxib (Vioxx) For relief of minor pain, analgesics such as acetaminophen (Tylenol) or a more powerful prescription drug For muscle pain, muscle relaxants such as cyclobenzaprine (Flexeril) For severe pain, strong prescription painkillers such as tramadol (Ultram); opiate agonists; or narcotics, which include oxycodone (OxyContin), propoxyphene (Darvocet) and meperidine (Demerol) For persistent pain in specific locations, injections of anesthetics such as lidocaine To alleviate sleep deprivation, low doses of tricyclic antidepressants such as amitriptyline (Elavil) and nortriptyline (Aventyl); sedatives such as zolpidem (Ambien); or selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft) Medications to treat other ailments that sometimes accompany fibromyalgia, such as irritable bowel syndrome, migraine headaches, restless leg syndrome and cold intolerance Is
There Any Alternative? Coenzyme Q10 may boost energy, fight off infection and improve cognitive functioning. Melatonin and valerian are believed to help promote deep sleep. Magnesium and malic acid are thought to relieve pain and fatigue. 5-hydroxytryptophan (5-HTP) helps improve sleep and mood and reduces carbohydrate cravings. St. John’s wort may ease depression. * Always check with your doctor before using supplements, as they can interfere with other medications. Clinical importance of changes in chronic pain intensity measured on an 11-point
numerical pain rating scale. The
application of these results to future studies may provide a standard definition of
clinically important improvement in clinical trials of chronic pain therapies. Use of a
standard outcome across Intrathecal Bupivacaine for Chronic Pain: A Review of Current Knowledge Unexplainable nondermatomal somatosensory deficits in patients with chronic nonmalignant pain in the context of litigation/compensation: a role for involvement of central factors?J Rheumatol 2001 Jun;28(6):1385-93 Mailis A, Papagapiou M, Umana M, Cohodarevic T, Nowak J, Nicholson K. Comprehensive Pain Program, Toronto Western Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada. MID: 11409135 OBJECTIVE: To address the prevalence and characteristics of nondermatomal somatosensory deficits (NDSD) in subjects with chronic pain in the context of compensation/litigation. METHODS: Data were collected via standardized history, examination, and patient- as well as physician-drawn body maps in a consecutive series of 194 subjects seen for the purpose of an independent medical examination. RESULTS: Forty-nine subjects (25.3%) with primarily widespread pain (often diagnosed as fibromyalgia) presented with hemisensory or quadrotomal deficits to pinprick and other cutaneous stimuli on the side of lateralized pain or worse pain. The NDSD limbs often had impairment of vibration sense (not infrequently associated with "forehead vibration split"), reduced strength, dexterity or movement, and extreme sensitivity to superficial skin palpation or profound insensitivity to deep pain. Spatial, temporal, qualitative, and evolutionary patterns of NDSD emerged associated with cognitive/affective symptoms. NDSD subjects were more often born outside Canada, more likely to be injured at work, present with abnormal pain behavior, and have negative investigations. CONCLUSION:
NDSD are a prevalent problem associated with chronic pain. Future research should explore
the prevalence of NDSD in other pain populations, the role of personality and related
factors, and the underlying biological substrate of these deficits. Efficacy and Safety of Intrathecal Opioid/Bupivacaine Mixture in Chronic
Nonmalignant Pain: A Double Blind, Randomized, Crossover, Multicenter Study Abstract - Opioids in non-cancer pain: a
life-time sentence? In
the case of ankylosing spondylitis, treatment was carried out for 2 years, stopped and
then restarted successfully. There were no withdrawal effects or addictive behaviour on Unexplainable nondermatomal somatosensory deficits in patients with chronic nonmalignant pain in the context of litigation/compensation: a role for involvement of central factors?J Rheumatol 2001 Jun;28(6):1385-93 Mailis A, Papagapiou M, Umana M, Cohodarevic T, Nowak J, Nicholson K. Comprehensive Pain Program, Toronto Western Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada. MID: 11409135 OBJECTIVE: To address the prevalence and characteristics of nondermatomal somatosensory deficits (NDSD) in subjects with chronic pain in the context of compensation/litigation. METHODS: Data were collected via standardized history, examination, and patient- as well as physician-drawn body maps in a consecutive series of 194 subjects seen for the purpose of an independent medical examination. RESULTS: Forty-nine subjects (25.3%) with primarily widespread pain (often diagnosed as fibromyalgia) presented with hemisensory or quadrotomal deficits to pinprick and other cutaneous stimuli on the side of lateralized pain or worse pain. The NDSD limbs often had impairment of vibration sense (not infrequently associated with "forehead vibration split"), reduced strength, dexterity or movement, and extreme sensitivity to superficial skin palpation or profound insensitivity to deep pain. Spatial, temporal, qualitative, and evolutionary patterns of NDSD emerged associated with cognitive/affective symptoms. NDSD subjects were more often born outside Canada, more likely to be injured at work, present with abnormal pain behavior, and have negative investigations. CONCLUSION: NDSD are a prevalent problem associated with chronic pain. Future research should explore the prevalence of NDSD in other pain populations, the role of personality and related factors, and the underlying biological substrate of these deficits. ACR: Lower-Back and Fibromyalgia Pain Linked, Possible Source Identified Lower back pain appears to be caused by a malfunctioning pain pathways in the brain, in a manner similar to fibromyalgia pain, University of Michigan researchers report. "These patients get bad reputation for claiming to feel pain in places where no physiological cause can be identified. It looks like the pain has a physiological source indeed, but in problems in the brain," said investigator Richard Gracely, Ph.D, professor of rheumatology at the University of Michigan School of Medicine in Ann Arbor told United Press International. The research was presented yesterday at the annual meeting of the American College of Rheumatology in New Orleans. The investigators enrolled 15 subjects experiencing chronic lower-back pain with no apparent physical cause, such as muscle, joint or bone injury. They also recruited 15 fibromyalgia patients and 15 normal control subjects. All subjects underwent functional magnetic resonance image (fMRI) scanning simultaneous with having a device apply pulsing pressure to the base of their left thumbnail. The variable pressure included painful and non-painful levels. The researchers noted that mild pressure caused subjects with lower-back pain and fibromyalgia to report significant pain, while control subjects tolerated the same pressure with little pain. Among the back pain and the fibromyalgia patients, the same mild pressure caused brain responses in areas that process the sensation of pain. The same brain responses did not happen in control subjects until pressure was raised substantially. All subjects showed increased activity in eight areas of the brain, but lower-back pain subjects showed no increased activity in two areas that were active in both fibromyalgia subjects and normal control subjects. The fibromyalgia subjects showed increased activation in two other areas not active in back pain patients and healthy subjects. The study indicated that lower-back pain patients have enhanced pain response in some brain regions, and diminished response in others, the investigators reported. The study offers the first objective method for correlating lower-back pain to unique brain activities at the precise moment of adverse feeling. The research might eventually lead to better treatments for lower back pain and fibromyalgia, by pointing toward certain brain regions where pain-inducing disorders might be located, Dr. Gracely noted. "So the bottom line is that fibromyalgia pain and lower-back pain are really 'real,'" said Nancy Derby, spokesperson and director of public policy and education for the National Fibromyalgia Association in Orange, CA. "This pain is a moving target, it seems, and perhaps now we see a bit better where it comes starts." Lower back pain is common, especially among overweight and sedentary people and those whose work is physically demanding. Lower back pain and problems stemming from it rank as the second most frequent cause of lost work days in adults under the age of 45, second only to the common cold. The study was supported in part by the National Fibromyalgia Research Association, the U.S. Army and the National Institutes of Health. Copyright © 2003 P\S\L Consulting Group Inc.
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