News Category: Pain

Pain is one of the most common reasons why someone goes to the doctor. This is for both acute (sudden) and chronic (long-term) pain. If non-medical treatment doesn’t work, such as rest, ice, exercise, for example, the next step is usually to use medications. Analgesics, medications to relieve pain, are among the most widely prescribed medications because of the high number of people who live with pain. Despite all that researchers have learned about pain management, many people are still experiencing moderate to severe pain, somewhere between 20 percent and 40 percent.

When treating rheumatoid arthritis, for example, doctors have available topical agents (creams or ointments), non-steroidal anti-inflammatory drugs (NSAIDs), opioids (controlled drugs, also called narcotics), and many other types of medications. Yet, most people with rheumatoid arthritis still experience a high level of pain. Cancer is another illness that can cause severe pain. It’s estimated that half of people with cancer do not receive adequate pain management.

Many studies that have looked into pain treatment and its effectiveness have been relatively short-term studies and, if the improvement is up to 30 percent, this is considered to be significant, or good. That leaves 70 percent without adequate relief. Understanding how pain management works would help doctors and researchers come up with better pain management strategies. The authors of this article looked into the consequences of finding “profoundly” effective pain relieving treatments.

When analgesics are used to relieve pain, the medications work to stop the cause of the pain, for example an anti-inflammatory will reduce inflammation and thus reduce pain, or to interrupt the pain messages to the brain, like opioids do. A local anesthetic, like a topical cream or something injected directly into the area numbs the pain so the sensation isn’t transmitted to the brain. The problem with medications is that not all medications work for all types of pain or all people. There are also side effects that can make the medications intolerable for some people.

Sometimes, an illness or syndrome may cause an altered sensation of pain and this has given researchers a different insight. People with these syndromes may not feel the pain as the body normally does. These conditions are rare, but researchers have found that part of the problem is the way the person’s body has a gene defect that reduces nerve growth factor signaling. Using this knowledge, researchers are working on medications that do the same thing, interfere with the nerve growth factor signaling.

In one study, done by Cox and colleagues, researchers studied three different families who had a congenital (born with) lack of sensitivity to pain. Although the children in the family were able to feel normal hot, cold, touch and motion, they couldn’t feel pain. Nerve tests didn’t find any abnormality, it just was as if they just did not feel pain.

Often, in medical reports of people who don’t feel pain, there are a lot of negative issues. For example, from birth, they may hurt themselves on purpose (self-mutilation) and have repeated accidents that can lead to severe injuries. But not all people with lack of pain are born that way either. Some come by this situation later on in life. People with diabetic neuropathy, a condition where people with diabetes have problems feeling their feet and toes properly, can develop severe injuries on their feet. They may not know they even have a blister or cut until it becomes infected and they happen to see it. It’s also been found that people with diabetes can have what is called silent ischemia. Ischemia is a condition where blood flow to the heart is restricted but usually causes chest pain. Silent ischemia means the person has ischemia, but there isn’t any pain. Other people who have altered or no pain sensation are those who have spinal damage that results in paralysis and lack of sensation below the injury.

So far, there hasn’t been any research in the psychological impact of children who don’t feel pain. Other than self-mutilation, researchers don’t know how lack of pain may affect how they see the world and themselves. However, it is thought that this lack of pain could and would lead to social and psychological disturbances.

So, knowing the drawbacks of eliminating pain completely, the whole issue of treating pain often comes down to a single problem, how much pain relief does each individual need? Should the ability to feel pain be eliminated completely? Some patients need or want much more pain relief than some others need. Whether this can lead to abuse of the drug or addiction also depends on many things, such as the level of pain, the patient’s pain threshold, the type of pain, and what is causing it, among other issues.

The potential for abusing some pain relievers, such as opioids, is a constant worry for many healthcare providers and for some patients as well. At this point, researchers haven’t found that profound analgesia, a deep analgesia, given to someone who isn’t in pain causes addiction. They also haven’t found that giving it makes people need more. But, there are concerns about some other issues that can come up with using analgesics to numb pain that hasn’t been experienced yet. This is the potential for people like athletes who want to play through the pain, perhaps causing more injury that can be more severe or even permanent. There is also a concern that the criminal element could get hold of this type of thing and then not think twice about getting hurt, because he or she wouldn’t feel it.

These concerns are all valid and upfront among researchers who are trying to find better and more effective methods of pain relief. In the search for adequate pain relief, should the goal be complete pain relief or elimination of pain? And if that is available, should this be offered to everyone or to a few people with specific types of pain? How would society be affected if all pain were eliminated?

The authors of this study wrote that some of the issues to be considered include the study process. They feel that the fewer patients involved in these studies, the better. Researchers would have to carefully watch for signs of accidental injuries and for self-mutilation. One thing to consider is that perhaps patients of limited time, those with cancer or are in palliative care for example, may be the right candidates for total elimination of pain.

They also wrote that the government would need to be aware of the research and at what level of development the medications are. There will need to be an evaluation as to whether these medications should be considered controlled or restricted medications as are opioids. Once the medications are available to the general public, doctors would need specific guidelines to help them understand which patient groups need this type of treatment and how to go about it.

In conclusion, the authors believe that although the medical community better understands pain, there’s still a lot of work that needs to be done. However, as we get closer to medications that may be able to eliminate pain, the ethical issue of who, where, and for what reason, will all need to be addressed.

It’s long been thought that depression and chronic pain were tightly connected. Both depression and chronic pain are common disorders in the Western world and both play a big role in the lives of patients, health care, and economics for employers. Many studies have found a connection between the two, leading researchers to believe that one influences the other in many patients.

The authors of this study looked at several studies and reviews. They found that some studies did imply that reducing pain would reduce depression and reducing depression would reduce pain. Therefore, by treating the depression, the pain would be managed successfully.

There are some explanations that could give some truth to the belief of the depression and pain connection. Serotonin and nonadrenaline, hormones, do play a role in depression and also in pain. For many people with certain types of chronic pain, antidepressants do help relieve the pain, specifically tricyclic antidepressants and dual reuptake inhibitors. However, the reverse doesn’t seem to be true – researchers haven’t found that pain relievers ease depression. In fact, they could – in some cases – worsen the depression or increase its risk.

Despite the studies showing that depressants can help relieve some types of chronic pain, other studies haven’t come to the same conclusion. Many studies have found that there could be connections between different life experiences and issues, from genetic to psychosocial to role behavior, and yet just as many studies found the opposite.

In this trial, the authors looked to find the relationship between depression and chronic pain using specific measures that have been recognized as being effective measurement tools by the research community. Researchers recruited 273 patients who had chronic pain and who were participating in a pain rehabilitation program. The patients were asked to assess their pain using the Short Form-36 (SF-36), which is the most frequently used survey used to determine a patient’s overall well-being. The researchers also used the Multidimensional Pain Inventory (MPI) to assess pain and its consequences, and the Hospital Anxiety and Depression Scale (HADS), which looks at depression and anxiety. The MPI and HADS scales were modified by the researchers so they were marked on a scale of zero (no pain, depression, anxiety) to 100 (the worst ever pain, depression, anxiety). The SF-36 pain scale was also zero (no pain at all) to 100 (worst pain ever), as was the SF-36 physical functioning scale.

There was a great range among the patients regarding how they rated their pain and depression with the MPI and HADS. However, there didn’t seem to be any correlation between how they rated their pain and how they rated their depression. Some patients rated their pain to be close to 100 while depression close to zero, and the other way around. There were enough patients who did rate higher pain and depression levels to allow for a weak association between the two, but this wasn’t strong enough to say that the two are definitely related. The researchers did find some relationship between patients who catastrophized their pain, thinking the worst would make the pain worse or bring it back, and pain level.

Pain management programs designed to help people manage their pain can approach management in many different ways. The researchers wrote, though, that all such programs should include interventions that look at and treat, if necessary, other issues, like depression or anxiety. The researchers found that there was a connection between anxiety and function, so if the patients are experiencing outside stressors, such as family issues or marital problems, these need to be addressed in order for pain to be treated.

The researchers concluded that there was not a strong basis behind the theory that depression and chronic pain are related, however if someone is stressed, this could have an impact on pain management.

It’s long been suspected that psychological issues can have a significant impact on chronic pain and how people perceive chronic pain. In the early days of human development, it’s thought that pain was a survival mechanism, an internal alarm of sorts. In order to not feel pain, humans would learn to adapt to their surroundings by not doing things that would cause pain or increase or intensify pain. This led to fewer injuries or less severe ones. However, this theory isn’t one that has been proven and it does have its flaws. New research is suggesting that if we are ever to be able to effectively treat chronic pain, we need to better understand the psychological/physical connection.

The authors of this article examined how pain catastrophizing and pain-related fear were connected to how people would protect themselves from developing more pain. This self-protection could be in the form of avoidance or “guarding” the painful area to prevent any possibility of more pain. The researchers predicted that the fear of movement or re-injury would be associated with pain protective behaviors and a reduction in physical activity and tolerance.

The researchers recruited 72 patients, who were an average age of 45 years) who had chronic musculoskeletal (bone, joint and/or muscle) pain. To participate, the patients had to have back or neck pain for at least three months and be away from work at the time of the evaluation for the study. The researchers measured the patients’ complaints of pain using the McGill Pain Questionnaire to measure how severe the pain was. This included a Pain Rating Index (MPQ-PRI). To see if patients were catastrophizing their pain, they used the Pain Catastrophizing Scale (PCS), which uses a scale of zero to four, with zero meaning never and four, all the time. Because many patients are fearful of pain or re-injury, the researchers chose to use the Tampa Scale for Kinesophobia (TSK) to measure this. The scale goes from one to four, with one being “strongly disagree” and four being “strongly agree.”

After the questionnaire were completed, the study participants were asked to lift different containers filled with sand made up to various weights. The tolerance of lifting was measured, as was the duration of the lift and the technique. If the patient experienced any pain, this was noted. The lifts were also videotaped for later review.

The researchers coded the behaviors of the patients as they picked up the objects. They looked for pain behaviors that were classified as either communicative or protective. Communicative behaviors included facial expressions and verbal utterances (grunts, moans, etc). Protective behaviors were ones that were meant to physically protect the patient against pain, such as guarding the area with a hand or rubbing it.

In analyzing the data, the researchers found that there was an association between catastrophizing and protective pain behaviors at a rate slightly higher than the association between catastrophizing and communicative behaviors. The results of the questionnaires and scales showed that women complained more than men about pain intensity and they also had higher rates over all on the Pain Catastrophizing Scale. Women also appeared to show more communicative and protective pain behaviors.

When interpreting data and trying to understand what the findings mean, it must be considered if protective behaviors are also communicative – using nonverbal communication and that these protective behaviors, such as rubbing the painful area, may be more intentional than verbal behaviors, such as grunting or moaning. There also may be a cultural component; some cultures are more verbal about pain while others are more stoic and are determined to not show any indication of discomfort. So, since there may be a more conscious decision to the behaviors than thought, this is not cut and dry, making it more complicated for the researchers to understand what is going on.

Despite the issues that aren’t yet understood, the researchers concluded that the pain catastrophizing was a related directly to both communicative and protective pain behaviors. Fear of pain, on the other hand, was related to physical tolerance and protective behaviors. Fear of pain did not affect pain severity though. It is felt that the study “provides additional evidence for the functional distinctiveness of pain expression and activity intolerance.”

Complex regional pain syndrome (CRPS) is a painful disorder that can occur after a seemingly minor trauma or accident. Although it usually begins after an injury, there are some people who do develop CRPS just like that, spontaneously. The pain of complex regional pain syndrome can be debilitating, affecting a person’s life severely.

Not all doctors are in agreement as to the criteria to be used to make the diagnosis. However, the most widely accepted criteria come from the International Association for the Study of Pain (IASP), which says that along with the pain and change in sensation, patients must have edema (swelling caused by fluid in the body tissue) of the injured area, changes in skin blood flow, and changes in the ability to use the limb.

As research continues, doctors are beginning to understand a bit of CRPS but it’s still not known if there are other illnesses, diseases, that may play a role in increasing the risk of developing the syndrome. The authors of this study wanted to identify if there were any other medical conditions that may occur in relation to the appearance of CRPS.

To do the study, the researchers looked back at files of patients with CRPS and compared them with people from the general population that did not have CRPS. The medical histories of the patients were evaluated as the researchers looked for evidence of other illnesses. If there were any questions about the history, the patients’ doctors were contacted for clarification. The researchers were particularly interested in traumas, any illnesses considered to be hormonal, metabolic, cancerous, inflammatory, or psychological. Any illnesses were classified as “unexplained complaints,” or “unexplained symptoms.”

What the researchers found was that of over 200,000 people, 259 were found to have CRPS. Since some weren’t reachable or their records traceable, the number of patients who could be included in the study was, in the end, 134. After losing some patients and adding some more, the researchers ended up with 186 patients, who were compared with 697 control patients, those who didn’t have CRPS.

When analyzing the data, the researchers noted that previously reported associations between osteoporosis and headaches and CRPS were also found in the study. They also found a connection between an increase in asthma attacks and menstrual cycle disorders. However, they didn’t find any connection with psychosocial factors, despite other studies finding otherwise.

It seems that migraines, asthma and CRPS share much in common with the inflammation process in the body. The researchers couldn’t find a connection between osteoporosis and menstrual related issues and CRPS, though. The authors did point out that there could be a connection with osteoporosis because of the increased risk of fracture, which is one of the predisposing factors of CRPS in many patients.

The authors concluded that there is a connection between a medical history of asthma, migraine, and osteoporosis, with CRPS. There may also be one with recent complaints of menstrual-related disorders or other illness that affect the nerves.

Fibromyalgia, a disease that is still not completely understood, is the subject of much research. Besides the fatigue associated with fibromyalgia, many people with fibromyalgia experience chronic pain that is difficult to treat. Other hallmark complaints are difficulty sleeping and depression. Now, along with these problems, researchers believe that many people with fibromyalgia also experience significant changes in their mental function.

Earlier research has found that cognitive disruptions in fibromyalgia seem to focus around memory and vocabulary. Another study found that people with fibromyalgia had difficulty doing tasks in a stimulus competition, with their ability declining as the stimulus competition increased. Yet another study that investigated the effect of chronic pain in general, found that people who lived with chronic pain also showed less ability to perform higher level tasks.

The authors of this article investigated the association of working memory disruption and declining performance in patients with fibromyalgia. The authors believed they would find that there would be a decline in this patient group and that how well they did would depend on the stimulus competition and the working memory.

Researchers studied 30 women with fibromyalgia and matched them with 30 women (controls) who did not have the syndrome. The women were assessed for pain using the Numerical Rating Scale (NRS), which asks the patients to draw a line across a horizontal line to illustrate their current pain level. The women also completed the McGill Pain Questionnaire (MPQ), which measures different qualities of pain. To assess attention functioning, both groups of women took the Test of Everyday Attention (TEA) and the Auditory Consonant Trigram (ACT), which asks for study subjects to remember three items lists of consonants after they had performed a task that was meant to distract them. Another test, the Reading Span Test (RST) assessed linguistic and nonlinguistic abilities. The researchers also assessed the quality of life using the 15D test. Finally, mental health was assessed using the Hospital Anxiety and Depression (HAD) scale and sleep was assessed by the patients recording how many of hours they slept each night.

After all the data were collected and analyzed, the researchers found that there were significant differences between the fibromyalgia group and the control group in terms of cognitive disruption, including depression, anxiety, how many hours of sleep per night, and how often wakening occurred at night. Women with fibromyalgia performed more poorly in tests for overall attention, stimulus interference, and working memory. But, the researchers did not find differences between the two groups regarding cognitive measures. The researchers did divide the fibromyalgia group into patients who took opioids (strong, controlled pain medications) and those who did not. The found that the patients who were taking regular, stable doses of opioids did do a bit better than those who were not. The authors pointed out that their study group was relatively small so it could be difficult to obtain a strong showing either way.

The authors wrote that there were some very strong differences between the fibromyalgia group and the control group in terms of mood, sleep disruption and pain that they experienced. There was also a link between cognitive disruption and the difficulties associated with depression, sleep deprivation, and anxiety. The authors went on to write that their beliefs going into the study were confirmed with their findings; that working memory is affected by chronic pain. They did point out, however, that there are some flaws to the study. These include the differences in medications that the patients may have been taking, the relationship between pain and fatigue that can be difficult to separate, as well as the small study size.

As more research points to the relationship between fibromyalgia and cognitive decline, research into the actual causes is moving forward. Using brain imaging, researchers have found that patients who have fibromyalgia also have higher levels of certain types of brain activity, but what this means remains to be learned.

When one spouse hurts, the other spouse is usually acutely aware of it. Having the understanding and support of a loved one can help us through painful conditions. But what happens when the pain lasts longer than expected? How do partners cope when the problem becomes chronic or even permanent?

Does the supportive partner remain as tuned in to the patient’s distress and needs? How accurately can the supportive spouse gauge the patient’s level of pain? And what is the effect on the relationship?

These are all important questions that social scientists are exploring. In this study, researchers from Canada look at the degree to which a partner’s sensitivity to a hurting spouse affects the marriage. They looked at the supportive spouse’s sensitivity to changes in pain and disability in their pained partner.

Chronic pain patients were filmed while lifting a series of heavy objects. Patients included in the study had neck or back pain lasting more than 12 months. Most patients reported long-term pain lasting many years. After the lifting activity, they rated their pain on a scale from zero (no pain) to 10 (severe pain).

Before lifting the weights, they filled out several surveys assessing pain, depression, and fear of reinjury. They also completed a 53-item questionnaire that measures psychosocial effects of chronic pain. This tool is called the Multidimensional Pain Inventory (MPI) (patient version).

After completing the lifting tasks, the patient’s spouses watched the videotape of the activity. The partner gauged the level of their spouses’ pain while lifting. The same zero to 10 scale was used. Each supportive spouse also filled out a survey called the MPI-spouse version.

The goal was to see how accurate the supportive spouse was in judging their partner’s pain. This value was referred to as empathic accuracy. The difference between patients’ reported pain and the spouses’ estimate of their partners’ pain was labeled the discrepancy index.

A second measure called the covariation index was also calculated. This reflects how sensitive the supportive spouses were to changes in the patients’ pain during all the lifting tasks (there were 18 objects to pick up).

Both measurements are needed to get an accurate idea of empathic accuracy. In the analysis of the results, there were no differences between men and women in their sensitivity toward their partner’s pain. The authors found several factors that influenced empathic accuracy. These included the pain patient’s facial and body expressions of pain, level of catastrophic thinking, and fear of reinjury. The supportive spouses own level of pain catastrophizing was evaluated, but it was not considered a contributing factor.

Most spouses were able to accurately estimate the partners’ pain during the lifting tasks. The also reported that patients in pain had worse outcomes when their spouse was aware of the patient’s pain. It appeared that patients with disabling pain showed more outward signs to alert their spouse of their pain.

Less empathic spouses were more likely to ignore the pain partner and express anger, frustration, or irritation toward them. There have been some other experts who suggest ignoring a spouses’ pain or inaccurately assessing pain may be a way to protect the relationship.

Previous studies have shown that fearful facial expressions and high levels of disability demonstrated by the patient are not relied upon by partners/spouses as much as by strangers observing the painful patient. The results of this study confirm those findings.

The authors suggest that spouses rely on more subtle indicators of pain that weren’t measured by the tools used in this study. Empathic accuracy may come from interactions between couples specific to each couple. Living with a person in pain over a long period of time may result in less obvious pain behaviors that are exhibited by the patient and perceived by the spouse.

And finally, having a highly empathic spouse was not an advantage. Patients with chronic pain whose spouse was in tune with their pain had lower function, less social activity, and worse outcomes. The authors conclude that it’s not necessary to have an accurate idea of a spouse’s pain to have a happy marital relationship.

More study is needed to fully understand empathic accuracy between couples in a marriage. The tools used in this study were accurate in judging pain. This is helpful information since there are many factors that can affect judgment of pain. Future studies can rely on the methods used in this study to help sort out all the other variables present.

Many chronic pain patients have been not been helped by traditional medical care. As a result, they have turned to alternative ways to deal with their pain. There isn’t much evidence yet to support complementary and alternative medicine (CAM) approaches. What do we know so far?

In this report, researchers review all systematic reviews published about a wide range of CAM treatments. They searched seven different databases to find articles on any treatment-related topics on CAM.

There were five systematic reviews that met the standard set of requirements for quality and design. Fifteen other trials also met the requirements to be included. Studies in all languages were accepted.

All patients included had chronic neuropathic or neuralgic pain. This means the primary (main) area involved was the nervous system. For this study, nervous system referred to two parts: the central nervous system (brain and spinal cord) or the peripheral nervous system (spinal nerves leaving the spinal cord).

Patients with multiple sclerosis, limb amputations, diabetes, shingles, and stroke were part of the studies. Symptoms of nervous system lesions included sensations of burning, stabbing, tingling, and/or numbness. There is no obvious change in the affected nerve when it’s examined. That’s why it’s been so hard to find a cure or effective treatment for this problem.

There were seven types of CAM treatments studied. These included acupuncture, electrostimulation, herbal medicine, magnets, dietary supplements, guided imagery, and spiritual healing. Here’s what they found:

Complex regional pain syndrome (CRPS), which used to be called reflex sympathetic dystrophy (RSD) is a puzzling illness for both doctors and patients. It’s a syndrome that doctors don’t understand as they don’t yet know what causes it. The syndrome causes intense pain that can be described as aching or burning. There can also be a change in skin color, the temperature of the skin over the affected area may feel different, and there may be sweating on just that area as well. Complex regional pain syndrome can occur after a minor injury, such as a pulled tendon or a bone break, but it can also happen after surgery, as well.

The doctors who see complex regional pain syndrome the most often are orthopedic surgeons and pain specialists, but the two groups don’t always diagnose the syndrome in the same way. Orthopedic surgeons usually see the syndrome in its early stages and still at a point when it may go away on its own. Therefore, the surgeons tend to treat complex regional pain syndrome with physiotherapy and pain relievers, ensuring that the affected joint keeps its normal movement. The pain specialists, however, see the syndrome when it has progressed far past the hopes that it may clear up on its own and it has likely not responded to any other treatments. Therefore, the specialist’s role is different than that of the surgeon’s role.

Although several studies have been done about diagnosis, there are differences between the retrospective studies, studies that look back and prospective studies, one that follow patients for a set amount of time. As well, here is a difference in the tools used to make the diagnosis. The authors of this study wanted to compare two methods of diagnosing complex regional pain syndrome to clarify the results of the earlier studies.

For the study, researchers looked at 262 patients who had fractured their radius, one of the lower arm bones, right next to the wrist. The group ranged in age from 17 to 93 years and was majority female (219 patients). All breaks were stabilized and casted; if the patient required surgery to repair the break, he or she wasn’t included in the study. As well, patients with any other arm injury were also excluded – the patients had to have just the wrist fracture.

After an average of nine weeks of when the patients first were seen (when the wrist was being set), the patients were assessed to see if they had any signs of complex regional pain syndrome, using two separate criteria. Their pain levels were assessed through testing and by asking the patients about the pain levels, and their hands were measured for temperature of the skin, how they perceived heat any swelling or muscle problems, and finger stiffness. According to one set of criteria, the Atkins Criteria, patients had to have an abnormal pain perception to heat in the fingers (dolorimetry), a high score (more than three out of 11) in measurement for blood flow in the hand, and abnormal joint stiffness.

For the second measurements, the Bruehl Criteria, the patients had to have abnormal pain and a symptom from each of the following four groups and an abnormal sign in two of the four groups: 1) abnormal sensations, 2) changes in the blood flow to the hand, 3) wasting away or muscle, difficulty moving the hand, and 4) swelling and sweating in the area.

When evaluating the findings, the researchers found that the number of cases of complex regional pain syndrome diagnosed were about the same using either criteria.: Bruehl criteria, 54 cases, and the Atkins criteria, 59 cases. There was disagreement between the two criteria in 19 cases, which seemed largely to be in assessing pain, blood flow, swelling, and joint stiffness. By the way the two criteria were measured, 12 patients who didn’t have any abnormal sensation to pain or heat had complex regional pain syndrome as measured by the Atkins criteria, but not by the Bruehl criteria. Four other patients who had normal dolorimetry measurements but abnormal sensations in their forearm had the syndrome if using the Bruehl criteria, but not if using the Atkins criteria. Yet another three patients were differently diagnosed because of their finger stiffness. They did have the syndrome if diagnosed with Bruehl criteria but not Atkins, although everything else in the Atkins criteria would have been acceptable.

Although there are several small differences in the two diagnostic criteria used by the doctors, the main difference appears to be how pain is perceived by the patient and the use of the finger to check for hypersensitivity. However, all else is very similar and lead to similar findings. The authors write that there were some limitations to their study, which may affect the outcome. The researchers did not use equipment to measure the temperature or color changes in the patients’ hands, but they pointed out that earlier studies have found that doctors are often able to do well by using their own assessment for these. The other drawback to the study is that only one doctor assessed the patients and didn’t have another opinion on the criteria measurements.

The authors concluded the article by stating that since there seemed to be little difference between the two criteria when diagnosing complex regional pain syndrome, they hope that this knowledge will allow the two main treating physicians to be able to work together more closely with their patients.

Spinal pain, or back pain, is very common in the Western world. In fact, it affects up to 80 percent of people at least one time in their life. Usually, the pain is nonspecific, not caused by any particular trauma or injury, or there isn’t any body part or tissue that has been noticeably injured.

Most often, nonspecific back pain goes away after three to 12 months, although most people do end up having more back pain later. And, among those people, an average of 16 percent experience back pain that’s bad enough to affect their every day life. This means the majority of people with nonspecific back pain don’t usually have any long-term problems and don’t even seek medical help.

Many studies have been done that have helped doctors understand things like catastrophizing (feeling that things worse than they really are), depression and feeling badly about oneself as a result of chronic pain. It’s been found that the amount of psychological distress felt by a patient affects how the patient feels pain and reacts to it. It can also predict how pain will be perceived. Other studies have been done to find how the length or duration of pain relates to disability, as well as pain and psychological status. Some of these studies have suggested that if someone is experiencing pain for 12 weeks or more, they should be watched for psychological effects from the pain. This is because it’s been found that most major improvements related to back pain occur during the first three months of pain.

Despite the many studies that have been done on back pain, not much has been done on the cognitive (thoughts and mental processes), physical, behavioral, and environmental factors that may play a role in how long nonspecific back pain stays. The authors of this article wanted to study thesevariables. Since most people with nonspecific back pain don’t seek help from their doctor, the researchers had to reach out to the community for study participants. To do this, they sent out questionnaires to 5000 adults, aged from 20 to 50 years, on a random basis.

To participate in the survey, the respondents must not have had a herniated disc (also called bulging disc or slipped disc), any rheumatic diseases (such as lupus or rheumatoid arthritis), fibromyalgia, or whiplash, nor could the women be pregnant. a total of 1815 people returned their completed questionnaire and 1024 complained that they had nonspecific back pain some time over the previous year.

More women than men complained of back pain (54 percent women). The group was broken down into three age groups. Those between 31 to 40 years made up 35.8 percent of the group; 41 to 50 years made up 35.5 percent, and the younger group, aged 20 to 30 years, made up 28.6 percent. Only 51.9 percent of the group had seen a doctor about the back pain.

The patients were asked to grad their back pain on the Graded Chronic Pain Scale, which has four categories: 1: low pain, low interference with life activities; 2: high pain intensity but low interference; 3: high interference that was moderately limiting activities; and 4: high interference that was severely limiting. The majority of the group, 85 percent, responded with 1 or 2.

The group was also divided into four categories describing their situation: 1: 100 reported that this was first time they’ve had back pain for less than three months (short-term); 2: 215 reported that this was repeat of short-term back pain; 3: 172 said their pain was present for more than three months but less than a year (medium-term back pain); and 4: 537 complained of pain for more than a year (long-term pain).

To get an idea of how the patients felt about their pain, the questionnaires asked questions about work satisfaction, pain vigilance, prevention or decreases in pain, how patients confronted their pain, if they did physically demanding work, their expectations about their pain, if they exercised, and if they did every day exercise.

In gathering the results, the researchers found that there were small but important differences between the groups regarding depression, catastrophizing, and pain expectation. There also may have been a difference in how they perceived social support (family, friends, employers). Patients who were in the groups of having longer periods of pain also had higher levels of catastrophizing and pain expectations. Those with long-term pain (longer than a year) also felt they had low social support. The article’s authors wrote that it wasn’t unexpected that “groups with longer pain duration expect pain to continue to a greater extent than groups with short-term pain, as individuals learn from their experience.”

When patients report back pain, neck pain, shoulder pain, or other local sites of body pain, it’s rare that they don’t have pain in other parts of the body as well. But most studies focus on an individual (local) area of pain. So the idea that low back pain is really present as part of a widespread pain pattern gets lost.

And with that clinical picture comes a different understanding of how local versus widespread pain affects patients’ lives. Widespread pain (present in multiple places of the body) results in decreased function, increased disability, and greater absenteeism in the workplace.

In this study, researchers from Norway verify the idea that localized back pain is rare. Most people really have low back pain along with painful symptoms in multiple other sites. They proved this by mailing questionnaires to over 3,000 people. They asked questions of adults in seven age groups. The people were between 24 and 86 years old. The age groups were divided by two-year intervals.

Everyone was asked to report if they had any pain or discomfort in any one or more of 10 different body parts. The symptoms were limited to two time periods: the last seven days and the past 12 months. The questionnaire included a body drawing to show a picture of the areas in question (head, neck, shoulder, elbow, hand/wrist, upper back, lower back, hip, knee, ankle/foot).

Each person completed a separate questionnaire about functional ability. Questions were asked about physical fitness, feelings, daily activities, and social activities. After compiling all the data, the authors focused on the past seven day period and found the following:

Pain pumps are often used after joint surgery to deliver a controlled amount of anesthetic and narcotic. This device provides good pain relief. Patients use less narcotic medication. But previous animal studies have shown that some drugs (lidocaine, bupivacaine) actually cause chondrocytes (cartilage cells) to die.

In this study, the effect of bupivacaine on chondrocytes in human articular cartilage samples is tested. The chondrocytes came from the femoral condyle of patients who had a total knee replacement. The femoral condyle is the round end of the femur (thigh bone).

The cells were scraped off and taken to a lab where they were prepared in a special culture. A system of pain pump to culture was set up. Medication was pumped into the culture plates in such a way as to mimic the way a normal, human joint would be treated.

Medications used included one-per cent lidocaine, one-per cent lidocaine with epinephrine, 0.25 per cent bupivacaine, 0.25 bupivacaine with epinephrine, 0.5 per cent bupivacaine, or 0.5 per cent bupivacaine with epinephrine. The amount of each drug used was similar to the dose given after surgery for pain control. Epinephrine is a stress hormone also known as adrenaline. It has many functions such as increasing the amount of oxygen supplied to the cells.

Samples were treated for 24-, 48-, and 72-hour trials. Control groups were used for comparison. The controls had chondrocytes in a culture media (solution) but without the drugs. The number of live cells in each sample (medication groups and the control groups) were counted before and after the drug trials. Accurate cell counts were done using digitally captured images and special computer software.

After 24-hours there was a significant decrease in the number of live cartilage cells in the medications that contained epinephrine. More than half the chondrocytes in the solution with lidocaine and epinephrine were gone.

The cell death rate was similar after 48-hours for the cells infused with any drug that contained epinephrine. At this point in time, samples containing one-per cent lidocaine also showed a decreased number of live chondrocytes. After 72-hours, cultures with 0.5 per cent bupivacaine showed similar losses of chondrocytes.

Overall, it looked like the death rate of chondrocytes increased with time. The combination of lidocaine and epinephrine had the worst results. These results may help explain reports of severe chondrolysis (breakdown of cartilage cells) after using intra-articular pain pumps.

The authors advise caution when using intra-articular pain pumps for more than 48 hours. Medications that have epinephrine in them should not be used at all. Bupivacaine (0.25 per cent) and lidocaine (one-per cent) are safe and effective during the first 48-hours post-op.

There are still many things that remain unknown about this experiment. Does the pH (acidity) of the medication make a difference in cell death? Would the epinephrine affect chondrocytes of young, healthy patients the same way? The patients in this study getting a total knee replacement were older adults with arthritis. Perhaps these cells are just more susceptible to damage.

Do knee chondrocytes respond differently to these drugs than chondrocytes from the hip or shoulder? Future studies are needed to answer these questions and find the optimal way to use intra-articular pain pumps after surgery.

Health care professionals depend on good sources of information to keep up-to-date on evidence-based medicine. One of the most reliable publications comes from the Cochrane Collaboration. Everyone pays attention when they publish a study.

The Cochrane Collaboration is a group of over 11,500 volunteers who systematically review all relevant randomized controlled trials on a specific topic. The people in the group are located in more than 90 countries. They also study the results of non-randomized, observational studies. The results of these systematic reviews are published in the Cochrane Library.

In this study, the use of nonsteroidal antiinflammatory drugs (NSAIDs) for low back pain (LBP) was reviewed. The goals were to 1) look for effects of NSAIDs and 2) find out which type of NSAID works the best. Specifically, COX-2 inhibiting NSAIDs were considered. These drugs have a lower risk of gastrointestinal side effects. For this reason, they have recently become more popular than the traditional NSAIDs.

The Cochrane reviewers searched for studies done on low back pain with NSAIDs. They found 28 trials that were of acceptable quality to be included. NSAIDs were compared with placebos, Tylenol, muscle relaxants, and other drugs (such as narcotics). Some studies compared traditional NSAIDs with the newer COX-2 inhibitors.

Patients included were adults age 18 and older with nonspecific low back pain with or without sciatica. Results were measured using pain, function, return to work status, and number of days off work. Other factors reviewed included side effects of the drugs, visits to a health care specialist, and general function. Range of motion, strength, and degrees of straight leg raising were also noted.

The reviewers used a rating system of levels of evidence to summarize the results of the studies. Outcomes were reported on a scale from no evidence to strong evidence. Moderate, limited, and conflicting evidence were in between on the continuum.

Any concerns about the way the studies were conducted or the design of the study were reported by the group. For example, follow-up was considered inadequate in more than half of the trials. Random selection and treatment groups were not always concealed as they should be to qualify as random-controlled trials. And in some studies, it simply wasn’t clear if the medication was being taken as prescribed.

When the data is of good quality, then results can be pooled together. This gives a much larger subset of results from which to make conclusions. In this meta-analysis, 11 studies on NSAIDs with placebo groups for low back pain qualified for pooling data. The results showed:

Research is underway to find out which patients with chronic pain can benefit most from the use of opioids to control pain. The word opioid refers to substances that act like morphine in the body. These are natural or manmade and have effects like the opium poppy.

The specific focus of this article is the effectiveness of opioids for chronic noncancer pain (CNCP). Several questions were raised. Is there evidence that opioids can be used with certain subgroups of chronic pain patients? Are the current clinical guidelines in use actually based on evidence available?

The current biopsychosocial theory of pain explains why some people develop chronic pain and others do not. This model suggests there are multiple factors that interact with each other to produce chronic pain. This includes biologic, psychologic, emotional, and social factors.

The studies reviewed showed that there are some risk factors to predict a poor outcome. Such things as a previous history of abuse, younger age, and pain at multiple sites or a lower pain threshold may interact together to move someone from acute to chronic pain.

There’s evidence that combining a wide range of treatment approaches may produce the best results. This could include psychologic or behavioral therapy, medications, physical therapy, or surgery. Whether or not opioids should be used right away or reserved for use when nothing else helps remains a hotly debated topic.

That’s why more researchers are looking for ways to predict who might benefit from these medications — not just who is more likely to misuse or abuse these drugs. The goal is to assess each patient and plan treatment that is individually tailored for that person. The final outcomes should be pain control, increased function, and improved quality of life. The idea is to provide these benefits while avoiding addiction or undermanagement of pain.

More information about pain mechanisms may be helpful. Genetic factors, psychologic health, and sensitivity to pain may be interconnected. Mood changes seem to be related to chronic pain more than intensity of pain. The results of several studies show that pain amplification and even catastrophizing pain may have an underlying genetic factor.

Other genetic factors are being considered. For example people metabolize drugs or move the drug through the body differently based on genetic traits. Type of pain receptors in the brain and in the body may be genetically determined. Even the tendency to become dependent or addicted to a drug may have a genetic basis.

In the future, it might be possible to do a simple genetic screening test to predict who might benefit from opioid use. Not only that, but physicians may be able to even predict which class of drugs or specific medication would work best for each patient.

Current clinical guidelines do not appear to be based on scientific evidence. More studies are needed to guide physicians in dispensing opioids for pain relief when and where these drugs can have the most effect.

Relying on opinion and theories or what’s always been done isn’t good enough anymore. Sound judgment in clinical decision-making based on solid scientific research should be the new standard.

The use of narcotic drugs such as opioids has been up and down over the years. Concern about dependence and addiction led to tighter controls on their long-term use. But an increase in support for their use in the late 1990s brought the debate back out into the open. As a result, there was a rash of studies done using opioids for chronic pain problems.

In this report, the issues are reviewed and the results of recent randomized-controlled trials (RCTs) are presented. Most of the studies done were with arthritic patients and people with neuropathic (nerve-related) pain. There had been some belief that opioids couldn’t treat neuropathic conditions effectively.

The studies all showed that opioids do, indeed, control pain in all conditions tested. But it should be noted that the studies were short-term and the doses used were moderate.

Although pain was well-controlled, this did not always translate into improved function. Function was defined differently in various studies but included motion, strength, activities, and work. Again, the assessments were all short-term in length. And some studies found that weak opioids worked well to improve function. Strong opioids worked better for reducing pain.

Given a choice, about half the patients discontinued opioid therapy. There were several different reasons for this decision. Some were concerned about adverse effects. Others obtained the desired pain relief. Those who continued using opioids for chronic pain had to increase the dose somewhat but did not experience addiction.

The authors report many problems with the studies themselves. Poor study design, bias in choosing patients, and trouble defining a positive result were just a few of the difficulties. Other factors may have also come into play. For example, the support of health care providers could not be separated from the effect of the drug.

There is a need for long-term studies with opioid therapy. But the problem with randomized-controlled trials is that some people don’t get the treatment they need. So it’s not practical to try completing this type of study for the number of years needed to answer the questions about long-term benefit of opioids for chronic pain conditions.

For now it’s clear that opioid therapy works well for short-term relief of pain. The long-term benefits are less obvious. More research is needed to understand the basic mechanisms of this drug. Identifying which patients can benefit most from this treatment is another answer needed from study of this potent medication.

Patients with chronic pain may be helped by strong pain relievers such as narcotics referred to as opioids. An opioid is a chemical substance that acts like morphine in the body. But these medications can be addictive, so there’s some concern about misuse and abuse.

In this study, researchers from the University of Washington reviewed articles from 1966 to 2007. They were looking for ways to predict who might be at risk for opioid misuse and/or abuse. Having this information would help physicians prescribe opioids. The goal is to help doctors choose patients who can benefit from this drug who are not at-risk for addiction.

Various methods were used to assess for patient behaviors suggesting opioid abuse. Depending on gut feelings was not reliable. Having patients fill out a survey answering questions about behaviors was also unreliable.

Urine screening may be the most accurate method of drug testing. But this isn’t as predictive of future behavior as it is an indicator of current drug misuse/abuse. Drug screening before prescribing opioids doesn’t really help sort out patients who are at-risk from those who aren’t.

Younger age does seem to increase the risk of medication misuse. But the role of gender (male versus female) was not clear. Most studies showed that women are not at increased risk for opioid abuse. The relationship between men and drug misuse was not as clear.

Probably the strongest predictor of drug misuse is a history of previous alcohol or other drug use. A family history of substance abuse may also be predictive. But this hasn’t been studied enough to say for sure. When used as prescribed, narcotic medications can be very effective without creating dependence and/or addiction. Signs that there may be a problem with misuse and/or abuse include:

Nicotine in cigarettes improves pain but doctors don’t recommend smoking for chronic pain patients. Studies show that patients with neuropathic (nerve-related) pain are more likely to smoke than patients with nociceptive pain. Nociceptors are pain receptors that detect mechanical, thermal, or chemical changes. Another word for this structure is nerve ending.

It’s not clear if smoking is more common among patients with neuropathic pain as a way to self-medicate or if this connection is just by chance. And although smoking can improve pain, there does not appear to be a clear link between pain level and number of cigarettes smoked (frequency).

Doctors encourage all patients to quit smoking. There are many health benefits from quitting tobacco use. No one knows for sure if quitting smoking would increase or decrease pain levels. Studies do not show that greater pain intensity leads to more frequent use of tobacco as might be expected.

Even though smoking can improve pain, smokers still tend to have greater pain intensity. They also report interference with mood and sleep because of pain. Results of treatment are less successful among smokers with chronic pain compared to nonsmokers. Future studies plan to look at the link between pain, smoking, and thoughts of suicide.

Patients who live with daily, chronic pain often report sleep disturbances. In this study, researchers from Johns Hopkins School of Medicine look at the relationship between nighttime sleep and daytime pain.

The study was done by telephone survey asking questions about daily pain, symptoms, and sleep periods. General health and body mass index were also measured. The data was used to assess daily pain as a function of the number of hours slept the night before.

Most of the patients reported sleeping between six and nine hours each night. Pain levels increased when the number of hours of sleep was less than six or more than nine. Pain levels predicted sleep and sleep effected pain the next day.

These findings may seem self-evident. But this is the first study to look at the day-to-day relationship between sleep and pain. The study also showed that younger patients with a higher BMI had higher levels of daily pain. So did patients with other chronic conditions or emotional disorders. Patients taking prescription drugs were also more likely to report higher daily pain ratings.

Some may wonder which came first? The pain causing poor sleep or poor sleep raising pain levels. The authors analyzed the data just to answer this question. They found that both pathways are important. But current sleep and next day pain levels had the greater significance.

There are several ways this information can be used. First, doctors may be able to use sleep patterns to predict who will have a good or poor outcomes after treatment for chronic pain syndromes. Second, finding ways to improve a person’s sleep may help relieve the pain.

And third, physicians may want to look at a patient’s report of increased pain more carefully. It could be nothing more than a poor night’s sleep. Thinking the condition is getting worse and ordering more and expensive tests may not be the best answer.

We still don’t know the specific mechanisms behind poor sleep and increased pain. More studies are needed to find the links between these two things. For the moment it seems important to ask each chronic pain patient a little bit about sleep patterns and work toward improving sleep.

Many people in chronic pain need medical help to manage their daily lives. Opioid medications are very helpful. But they have the adverse side effect of dependence and addiction.

In this article, staff from the Pain Management Center at the Brigham & Women’s Hospital in Boston offer a review of the problem. They clear up some confusion about the terms used such as misuse, abuse, dependence, tolerance, and addiction.

They offer physicians a strategy for helping manage patients taking high-risk medications. The first step is to recognize risk factors for opioid misuse. A special screening tool can be used to help in this process.

A personal or family history of substance abuse is a red flag. Other risk factors include heavy tobacco use, risk-taking or thrill-seeking behavior, and history of depression or anxiety. Previous alcohol or other drug rehab can be predictors of future drug problems. Likewise, a history of criminal activity or legal problems are also important risk factors.

Patients at risk for drug misuse or abuse can be asked to sign a treatment agreement. The agreement includes statements of intention. For example, I will use the substances only as directed by my doctor. I will get these drugs only from one doctor. Any drugs lost or stolen will not be replaced.

Controlled substance agreements help improve patient cooperation. They provide education and guidance about acceptable behavior when taking these drugs. There must be agreement not to use recreational drugs or prescription meds from anyone else.

Patients must agree to see a trained behavioral counselor or psychologist for addiction counseling and pain management. Routine but random drug testing is also required. And the patient must keep regularly scheduled appointments with doctors and counselors. Failure to comply with each step may mean discharge from treatment with opioids.

Although the interdisciplinary pain rehabilitation approach to management of chronic pain is effective, some patients relapse following successful treatment, back to their previous level of function. This is often referred to the goal violation effect (GVE). The authors of this article write that despite the relapses, little attention has been placed on the reasons why they may occur.

This study investigated the unmet goals in five categories (coping strategies, medication, exercise, social activities, and work). The researchers felt that the GVE could be greater for certain goals than others. The study investigated if patients’ attributions to the unmet goals were consistent with the GVE and if the GVE was different depending on the individual unmet goal.

One hundred patients with chronic pain (longer than six months) that interfered with their daily living completed the study. They participated in a four-week program that provided them with a review of pain medications and appropriate adjustment or termination of medications, progressively increasing exercise and physical activity, pain coping and relaxation skills, and psychologic, social, family and vocational issues were identified and treated.

In the final week, issues related to relapse were addressed. The facilitator used an example of a gambler and the high-risk behaviors that can lead to relapse. Coping skills were discussed to encourage study subjects to recognize the issue and to find ways to avoid relapse.

Follow up was six months later; the subjects received in the mail a questionnaire asking them if they had met their goals. If the goals were unmet, they rated them according to why. According to the scoring system, a higher score indicated internal causes, rather than external. A GVE was calculated for each unmet goal.

According to the findings, 46 of the 100 patients failed to meet less than one-third of their goals. Thirty eight failed to meet between one-third and two-thirds, and 16 failed to meet more than two-thirds.

The researchers found that the results were consistent with those from previous studies. Patients who live with chronic pain and who don’t meet their objectives, make attributions consistent to the GVE. Interestingly, the attributions differed according to the unmet goal. For example, work and social goals had lower internal attributions than did the other three goals. In fact, work had the highest external attribution because of reasons that were often out of control of the subject.

Since the causes of unmet coping skills, medication, and exercise were mostly internal, patients could end up feeling more guilt and self-blame, which could be the beginning of a cycle that resulted in relapse.

The authors wrote, “Teaching patients how to deal with lapses, flare-ups, and set backs is one component of proposed relapse prevention strategies. Other relapse program components include discussion of the importance of adherence, addressing the patient’s understanding of the recommendations, anticipating high-risk situations, encouraging self-monitoring and self-reinforcement, and enlisting the support of others.”

In conclusion, the authors noted that the use of cognitive-behavioral relapse prevention strategies have been advocated but not followed through. The results of this study suggest that this type of approach would be beneficial for patients with chronic pain.

Chronic pain is an increasing problem in the developed world, however, limited medical resources are causing longer than desirable waiting periods for assessment and treatment for the pain. According to recent statistics, chronic pain affects 15 percent to 29 percent of the general population.

The authors of this article reviewed the access to chronic care treatment and the effects of increasing waiting times.

Researchers reviewed the literature to identify studies that reviewed chronic pain (pain over six months’ duration) and wait time between referral and assessment/treatment. Fourteen trials involved wait times of 10 weeks or less, of which six no changes in patients’ level of chronic pain. Three trials showed patient improvement during the wait, five trials showed deterioration.

Four trials involved wait times of 12 weeks or longer, with only one showing no change in patient status; the remaining trial subjects showed significant deterioration.

Two studies involved waits of up to six months. Both had significant patient deterioration rates.

The authors concluded that waits of six months from time of referral to treatment – which does not include the time between initial presentation of symptoms and referral – is associated with significant deterioration and depression among patients with chronic pain.