Facet Joint Effusion And Interspinal Ligament Edema: Major Sources Of Lower Back Pain

New MR techniques show that facet joint effusion (the collection of fluid in the spinal joints) and interspinal ligament edema (swelling of the interspinal ligaments) are major sources of lower back pain, according to a study performed at Baskent University Hospital in Ankara, Turkey and Alanya Research Center in Antalya, Turkey.During the study 372 patients with lower back pain and 249 healthy patients underwent MRI accompanied by STIR (short inversion time inversion recovery) sequences. “The most common imaging findings in patients with lower back pain were soft tissue changes, mainly facet joint effusion, 85.5%, and interspinal ligament swelling, 80.6%,” according to Nefise Cagla Tarhan, MD, lead author of the study.

“Soft tissue changes are important in the understanding of lower back pain and prevention and treatment options should focus more on these changes. A lot of patients (mostly younger) come to me with complaints of bad, lower back pain; it is a very common community problem,” said Dr. Tarhan.“With this new MR technique, prevention and treatment options for lower back pain can focus more on soft tissue degenerative changes that cause facet joint effusion and interspinal ligament swelling,” said Dr. Tarhan.

Patients Who Recover From Coma But Cannot Communicate Feel Pain

Do patients who survive a severe brain injury but fail to recover speech or non-verbal communication perceive pain? After their remarkable publication where they showed that a patient in a vegetative state in reality was conscious, scientists at the University of Liège (ULg) were able to tackle the very difficult issue of pain perception in coma survivors.

The Coma Science Group of the Cyclotron Research Centre and Neurology Department of the ULg used PET scanning to measure minimally conscious and vegetative patients’ brain activation in response to noxious stimulation.

After comparing results obtained in the different patient groups with those in healthy volunteers who could communicate it felt painful they concluded that minimally conscious patients must feel pain despite being unable to tell their environment. Hence, these patients should receive pain-killers, the authors concluded.

This study has major ethical and therapeutical consequences also with regard to end-of-life decisions in these challenging but vulnerable patient populations.

The study was led by Pr Steven Laureys from the Coma Science Group of the University of Liège and will be published in October in the journal Lancet Neurology.

Nerve Stimulation Therapy Alleviates Pain For Chronic Headache

A novel therapy using a miniature nerve stimulator instead of medication for the treatment of profoundly disabling headache disorders improved the experience of pain by 80-95 percent, according to a new study from the University of California, San Francisco and the National Hospital for Neurology and Neurosurgery in London.

The findings give doctors the promise of a non-drug treatment option for pain sufferers unable to tolerate indometacin, the standard medication known to cause stomach bleeding in some patients. Findings are reported online at http://www.thelancet.com and also will appear in the November 2008 issue of Lancet Neurology.

Up to 35 million Americans suffer migraine and other forms of headache, according to the American Academy of Neurology.

“We need a range of treatments to offer patients whose lives are taken over by debilitating headaches,” said Peter J. Goadsby, MD, PhD, lead author, neurologist and director of the UCSF Headache Center. “It’s quite exciting to think about how technology will advance in the next five years to provide remarkable devices for the treatment of headache. Preventive approaches like these will completely change the landscape of headache treatment.”

The device, called a bion, is a rechargeable battery-powered electrode, similar in size to a matchstick. When implanted near the occipital nerve in the back of the neck, it alleviates pain by generating pulses that the nerve receives. The bion can be turned on or off via an external wireless remote control. Previous versions of the bion have been used in pain management for osteoarthritis and in the treatment of dislocated joints for patients recovering from stroke.

The study measured the effectiveness of nerve stimulation in six patients aged 37 to 64 with hemicrania continua, a rare headache disorder defined by the International Headache Society as a form of chronic daily headache in which patients have 15 days or more of headache per month.

At the beginning of the study, participants underwent a minimally invasive surgery to have the bion implanted at the occipital nerve. Each participant then received continuous stimulation of the nerve for the first three months. The device was switched off for the fourth month, ensuring that patients did not receive stimulation of the occipital nerve during that time, and switched on again at month five.

Switching off the bion enabled researchers to measure whether the device – rather than the placebo affect – was responsible for pain modulation.

To test long-term safety and efficacy of nerve stimulation therapy, follow-up sessions with the patient, a researcher and a device technician occurred once per month for four months.

Patients kept diaries, at hourly intervals during waking hours, which included a pain severity scale ranging from 1 to 10 points. Participants shared their diaries with researchers after the fifth month.

Researchers found that within a range of six to 21 months after implantation of the bion, five of the six patients reported sufficient benefit to recommend the device to other patients with hemicrania continua. Similar results were reported in 2007 by two other research teams studying patients with chronic cluster headaches.

At long-term follow-up, four of the six patients reported substantial pain improvement at a level of 80 to 95 percent, one patient saw a 30 percent improvement, and one patient reported that his pain worsened by 20 percent.

Overall, the research team found that participants not only improved with the bion therapy, but their pain worsened when the bion was switched off during the fourth month. In addition, diary submissions revealed an overall reduction in the pain score of five to eight points.

“The treatment of migraine and other chronic headache pain can be a considerable challenge to physicians. Not all patients can tolerate the appropriate medicines, and the side effects leave patients and doctors in a difficult position,” Goadsby said.

“We have the opportunity to afford a huge change in quality of life for these patients. The bion was well tolerated, and neuromodulation is proving an effective and safe option, particularly in cases when patients have difficulty stomaching indomethacin.”

The study is the first systemic use of the second generation of neurostimulators for the alleviation of primary headache, according to researchers. Occipital nerve stimulation is currently being studied for use in migraine treatment.

The study received external support from Boston Scientific Neuromodulation.

Co-authors on the paper were Brian Burns, MRCP, and Laurence Watkins, FRCS, of the Institute of Neurology at the National Hospital for Neurology and Neurosurgery, London.

Black Patients With Chronic Pain Less Likely To Have Obesity Assessed

At the intersection of two U.S. health epidemics – obesity and chronic pain – researchers from the University of Michigan Health System found black patients with chronic pain were less likely to have their weight or body mass index (BMI) recorded, even though they are at higher risk for having obesity when compared with their white counterparts.

This new study also revealed that obesity is related to greater disability and poorer functioning, over and above the impact of a person's pain level.

Obesity contributes to chronic pain and several other chronic conditions, leading to decreased health and quality of life. Chronic pain also leads to decreased health and quality of life, says senior author Carmen R. Green, M.D. Disparities in the chronic pain experience and obesity exist, with blacks more likely to be negatively impacted, she notes.

Black people also are more likely to experience disability and lower physical functioning than white people, when faced with chronic pain, says Green, associate professor of anesthesiology and health management and policy, and director of Pain Medicine Research at the U-M Medical School and School of Public Health. The study appears in the Journal of Pain.

"Assessing a patient's weight and height is necessary to calculate BMI. Once assessed, a dialogue can begin between the patient and health care team to address obesity," Green says. "These findings provide further evidence of the negative effect obesity, measured via BMI, can have on a person's overall health and well-being in general and on chronic pain in particular.

"This is a reminder about the importance of assessing height and weight and measuring BMI in patients with chronic pain, especially minorities."

However, the goal is made more difficult because black patients are less likely to have their BMI assessed, the study found. "Both chronic pain and obesity are reaching epidemic proportions. Considering their public health implications in terms of disability, BMI should be regularly assessed especially in populations who are at increased risk," Green says.

It is not clear why it was less likely black patients would have their BMI measured, even though they may be at increased risk for higher BMI and obesity, researchers say. But they point out that the gap could indicate a lower quality of care than what is provided to white patients.

BMI is a measure of body fat based on height and weight. According to the National Institutes of Health, people with a BMI lower than 18.5 are considered underweight; people between 18.5 and 24.9 are normal weight; people between 25 and 29.9 are overweight; and those with a BMI of 30 or higher are obese. This table shows the BMI of people at various weights and heights.

By the numbers:

Researchers studied 183 people – 92 white and 91 black, 68 men and 115 women, ages 31 to 46. New black patients attending a pain clinic at U-M were asked to participate, and were matched with a white chronic pain patient of the same gender and similar age.

When the height and weight was available it was taken from the electronic medical record. Patients were asked to indicate on a diagram of the human body where they were in pain, how long they've been in pain and what caused it. They also were given the McGill Pain Questionnaire and the West Haven Yale Multidimensional Pain Inventory to evaluate the intensity of their pain and its impact on their life.

The BMI was notably higher for blacks than whites (31.6 vs. 27.6). Blacks were less likely to have complete height and weight data in their records than whites (73 percent vs. 84 percent). Those without BMI data had higher pain severity scores.

In addition to Green, Julia Caldwell, M.D. and Tamera Hart-Johnson, M.S. were co-authors of the paper.

AETNA Quality Care Foundation provided funding for the study.

Pain Automatically Activates Facial Muscle Groups

A study has found that people who facially express pain in a more intense way are not exaggerating if their perception of a painful stimulation is controlled. The study conducted by Miriam Kunz is published in the November issue of Pain.

The study was conducted on 20 men and 20 women between the ages of 18 and 30. Kunz placed a heating device on their leg to provoke the painful stimulus. During the test, Kunz asked the test subjects to push a button when the heat became moderately painful as she filmed their facial expressions.

"Individuals who react to pain with intense facial expressions are in fact feeling more pain if we rely on quantitative verbal measures independent of the painful experience," says Kunz, a postdoctoral student at the Université de Montréal Faculty of Dentistry, Department of Stomatology, and the Institut universitaire de gériatrie de Montréal.

However, they have a lower tolerance for pain. "All test subjects with an intense facial reaction to pain estimated that the sensation was "moderately painful" between 45 and 47 degrees Celsius, while others had a higher threshold," she says.

All individuals have a non-verbal mode of communication influenced by culture, education, age, sex, etc. This mode relies on innate and universal programming. That is why a blind child knows how to smile, even if he has never seen his mother smile. "Pain, just like joy, sadness, fear, surprise, anger and disgust automatically activate certain muscle groups that make the expression appear on the face," says Kunz.

Fibromyalgia Can No Longer Be Called The 'Invisible' Syndrome

Using single photon emission computed tomography (SPECT), researchers in France were able to detect functional abnormalities in certain regions in the brains of patients diagnosed with fibromyalgia, reinforcing the idea that symptoms of the disorder are related to a dysfunction in those parts of the brain where pain is processed.

"Fibromyalgia is frequently considered an 'invisible syndrome' since musculoskeletal imaging is negative," said Eric Guedj, M.D., and lead author of the study. "Past imaging studies of patients with the syndrome, however, have shown above-normal cerebral blood flow (brain perfusion) in some areas of the brain and below-normal in other areas. After performing whole-brain scans on the participants, we used a statistical analysis to study the relationship between functional activity in even the smallest area of the brain and various parameters related to pain, disability and anxiety/depression."

In the study, which was reported in the November issue of The Journal of Nuclear Medicine, 20 women diagnosed with fibromyalgia and 10 healthy women as a control group responded to questionnaires to determine levels of pain, disability, anxiety and depression. SPECT was then performed, and positive and negative correlations were determined.

The researchers confirmed that patients with the syndrome exhibited brain perfusion abnormalities in comparison to the healthy subjects. Further, these abnormalities were found to be directly correlated with the severity of the disease. An increase in perfusion (hyperperfusion) was found in that region of the brain known to discriminate pain intensity, and a decrease (hypoperfusion) was found within those areas thought to be involved in emotional responses to pain.

In the past, some researchers have thought that the pain reported by fibromyalgia patients was the result of depression rather than symptoms of a disorder. "Interestingly, we found that these functional abnormalities were independent of anxiety and depression status," Guedj said.

According to Guedj, disability is frequently used in controlled clinical trials to evaluate response to treatment. Because molecular imaging techniques such as SPECT can help predict a patient's response to a specific treatment and evaluate brain-processing recovery during follow-up, it could prove useful when integrated into future pharmacological controlled trials.

"Fibromyalgia may be related to a global dysfunction of cerebral pain-processing," Guedj added. "This study demonstrates that these patients exhibit modifications of brain perfusion not found in healthy subjects and reinforces the idea that fibromyalgia is a 'real disease/disorder.'"

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, fibromyalgia syndrome is a common and chronic disorder characterized by widespread muscle pain, fatigue and multiple tender points. Tender points are specific places—for example, on the neck, shoulders, back, hips, and upper and lower extremities—where people with fibromyalgia feel pain in response to slight pressure. The syndrome is one of the most common causes of musculoskeletal pain and disability and affects three to six million, or as many as one in 50, Americans. Between 80 and 90 percent of those diagnosed are women.

Although fibromyalgia is often considered an arthritis-related condition, it does not cause inflammation or damage to the joints, muscles or other tissues. Like arthritis, however, the significant pain and fatigue caused by fibromyalgia can interfere with a person's ability to carry out daily activities.

MRI Reveals Relationship Between Depression And Pain

The brains of individuals with major depressive disorder appear to react more strongly when anticipating pain and also display altered functioning of the neural network that modifies pain sensitivity, according to a new report.

"Chronic pain and depression are common and often overlapping syndromes," the authors write as background information in the article. Recurring or chronic pain occurs in more than 75 percent of patients with depression, and between 30 percent and 60 percent of patients with chronic pain report symptoms of depression "Understanding the neurobiological basis of this relationship is important because the presence of comorbid pain contributes significantly to poorer outcomes and increased cost of treatment in major depressive disorder."

Irina A. Strigo, Ph.D., of the University of California San Diego, La Jolla, and colleagues studied 15 young adults with major depressive disorder (average age 24.5) who were not taking medication and 15 individuals who were the same age (average 24.3 years) and had the same education level but did not have depression. Patients with depression completed a questionnaire that evaluated their tendencies to magnify, ruminate over or feel helpless in the face of pain. All participants underwent functional magnetic resonance imaging (fMRI) while their arms were exposed to a thermal device heated to painful levels (an average of 46.4 degrees to 46.9 degrees Celsius, or about 115 degrees to 116 degrees Fahrenheit) and also to non-painful temperatures. Visual cues (a green shape for non-painful warmth and a red shape for painful warmth) were presented before the heat was applied.

Compared with the controls, patients with depression showed increased activation in certain areas of their brain—including the right amygdala—during the anticipation of painful stimuli. They also displayed increased activation in the right amygdala and decreased activation in other areas, including those responsible for pain modulation (adjusting sensitivity to pain), during the painful experience.

To examine whether the activation of the amygdala was associated with passive coping styles, the researchers compared the percentage change in the activations of the amygdala with the helplessness, rumination and ramification reported by the participants with depression. "Significant positive correlations were observed in the major depressive disorder group between greater helplessness scores and greater activity in the right amygdala during the anticipation of pain," the authors write.

"The anticipatory brain response may indicate hypervigilance to impending threat, which may lead to increased helplessness and maladaptative modulation during the experience of heat pain," the authors write. "This mechanism could in part explain the high comorbidity of pain and depression when these conditions become chronic."

"Future studies that directly examine whether maladaptive response to pain in major depressive disorder is due to emotional allodynia [a pain response to a non-painful stimulus], maladaptive control responses, lack of resilience and/or ineffectual recruitment of positive energy resources will further our understanding of pain-depression comorbidity," they conclude.

This study was supported by Barrow Neurological Foundation, grants from the National Institute of Mental Health, the National Association for Research in Schizophrenia and Depression and the University of California San Diego Center of Excellence for Stress and Mental Health.

Long-term Benefits Of Morphine Treatment In Infants Confirmed In Rodent Study

A recent study conducted by researchers at Georgia State University is the first of its kind to demonstrate that administration of preemptive morphine prior to a painful procedure in infancy blocks the long-term negative consequences of pain in adult rodents. These studies have serious implications for the way anesthetics and analgesics are administered to neonates prior to surgery.

Infant rodents that did not receive preemptive pain medication prior to surgery were less sensitive to the effects of morphine in adulthood.

This means that infants undergoing invasive procedures at birth that do not receive any pain medicine will require more morphine in adulthood to modulate their pain.

This study -- conducted by Anne Z. Murphy, Ph.D., a GSU Professor of Neuroscience and member of the Center for Behavioral Neuroscience, and graduate student Jamie LaPrairie -- has serious clinical implications for the more than 400,000 human infants that are admitted to a newborn intensive care unit (NICU) in the United States each year.

Past studies have shown human infants born between 25-42 weeks gestation experience on average 14 painful procedures per day during the first two weeks of life with fewer than 35 percent receiving appropriate analgesic therapy.

"While such surgical procedures in preterm infants are clearly necessary, the resulting pain and inflammation has been shown to lead to negative behavioral consequences later in life," Murphy said. "Our previous studies have shown that, just as in humans, neonatal inflammation in rodents (that did not receive preemptive pain medication) results in an increase in sensitivity to pain, stress, and decreased reaction to morphine as adults.

While evidence exists that morphine is efficacious in neonatal rodents, this is the first study to confirm the long-term behavioral benefits.

In this study, published online in Pediatric Research, a group of rat pups received an injection of morphine sulfate on the day of birth prior to inducing inflammation; another group received a saline injection instead. The groups were then raised identically and received identical procedures during a 60-day period. Rodents that received preemptive morphine behaved normally while those rats that received saline showed significant increases in pain sensitivity and were resistant to the pain relieving effects of morphine in adulthood.

"This tells us that morphine doesn't work very well in human children and adults that were formally in the NICU and didn't receive preemptive pain treatment, and since morphine is still the primary drug used to treat severe pain, this means that there is an entire subpopulation for which morphine doesn't work efficiently," Murphy said. "These results suggest that there are long-term benefits of providing all newborns with some sort of pain relieving medicine prior to the initiation of an invasive procedure."

Murphy's work was supported by the National Institutes of Health, the Center for Behavioral Neuroscience, and the GSU Brains and Behavior Program.

Chronic Pain Might Contribute To Suicidal Thoughts

New research suggests that patients with chronic pain are more prone than others are to consider suicide. The increased risk remained even when study authors took the possible influence of mental illness into account.

“This is further evidence that we need to be aware of the heightened risk for suicide in those with chronic pain,” said Mark Ilgen, lead study author. “More work is needed to figure out who’s going to be at the greatest risk and how can we intervene and decrease this risk.”

Ilgen and colleagues conducted the study to gain perspective on the link between pain and suicide in the public. Most prior research on this topic had looked only at patients already receiving treatment for their pain, said Ilgen, a psychologist at the Ann Arbor VA Hospital and assistant professor at the University of Michigan.

The researchers examined information collected during a 2001 to 2003 epidemiological survey of 5,692 English-speaking adults in the United States who answered questions about chronic pain and suicidal thoughts in the last 12 months.

The study findings appear in the November/December issue of the journal General Hospital Psychiatry.

After adjusting the figures to account for the effect of mental illness and chronic physical conditions, the researchers found that those who suffered from head pain were almost twice as likely as others to report having suicidal thoughts. They were also more than two times as likely to report suicide attempts.

Those with other types of pain not related to arthritis were four times as liable to have tried to commit suicide.

The researchers also found that almost 14 percent of those with three or more pain conditions reported suicidal thoughts and almost 6 percent of these individuals reported a suicide attempt.

“Pain is one of those factors that may make someone feel more hopeless and less optimistic about the future and increases the chances that they will think about suicide,” Ilgen said.

Still, “the vast majority of people with any of these forms of pain are not suicidal,” he said.

Thomas Joiner, a psychology professor at Florida State University who has written a book on suicide motivations, said people accustomed to pain might think they could tolerate suicide.

“The natural and deep fear of pain, injury and death stops people from hurting themselves, and this includes people who have high desire for suicide,” Joiner said. “It might not be as hard for someone who has already had to contend with a lot of physical pain.”

“This particular view has not gotten enough attention, probably because, in the public mind, a kind of fearlessness does not seem to fit with suicide. But here, the public mind is mistaken,” Joiner said.

Ilgen MA, et al. Pain and suicidal thoughts, plans and attempts in the United States. General Hosp Psychiatry, 30(6)), 2008.

Wasabi Receptor Can Sense Ammonia That Causes Pain

A Japanese research group, led by Prof Makoto Tominaga of National Institute for Physiological Sciences in Japan, has found that the receptor for hot taste of wasabi, Japanese horseradish usually eaten with Sushi, can sense alkaline pH caused by base such as ammonia.

The team reports their finding in Journal of Clinical Investigation on November 13, 2008.

Clinically, alkaline pH is known to cause pain but the mechanism has been not known. By electrophysiological experiments, the team found that the WASABI receptor, namely transient receptor potential (TRP) A1 receptor, can be activated by alkalization inside of cells by application of base such as ammonia.

Administration of such base to the foot of mice caused transient pain-related behaviors. However, it did not in TRPA1 deficient mice.

"It has the first report showing molecular entity for the alkali-sensor. You could feel pain when you eat too much WASABI with Japanese Sushi. We found that this pain sensation is the same with that caused by ammonia", said Prof Tominaga.

Pain And Itch Responses Regulated Separately

Historically, scientists have regarded itching as a less intense version of the body's response to pain, but researchers at Washington University School of Medicine in St. Louis have determined that pain and itch actually are regulated by different molecular mechanisms.

At Neuroscience 2008, the annual meeting of the Society for Neuroscience, the researchers report they have separated itch and pain sensations in mice, a finding that could have important implications for treating both pain and chronic itching. The two problems often occur together because when patients are treated with strong drugs for pain, itching is a common side effect.

Last year, the research team, led by Zhou-Feng Chen, Ph.D., an investigator at Washington University's Pain Center, was the first to identify an itch gene. The scientists published those findings in the journal Nature. Now, further experiments have demonstrated that pain signals are not affected when mice are bred without the itch gene or the gene's actions are blocked.

The itch gene, called GRPR (gastrin-releasing peptide receptor), makes a receptor found in a very small population of nerve cells in the spinal cord. That region of the spinal cord transmits pain and itch signals, as well as temperature sensation, from the skin to the brain. When exposed to itchy stimuli, mice without the gene scratched less than their normal littermates.

"There are two major types of itching," says Chen, an associate professor of anesthesiology, psychiatry and developmental biology. "There is histamine-dependent itching caused by bug bites or allergic reactions, the kind of itching that can be treated with antihistamine drugs, such as Benadryl®. But the majority of chronic, severe itching is resistant to antihistamine treatment."

Many patients with chronic pain receive spinal injections of opioid drugs, such as morphine, to control their pain. One of the well-known side effects of that treatment is itchy skin.

"Most scientists believed that the itching could not be separated from the drug's pain-killing effects," Chen says. "This type of itching cannot be relieved by anti-histamine treatment. We hypothesized that GRPR may be responsible for the itching but not involved in the pain response."

So Chen's team went back to the mice bred with and without GRPR and compared both scratching behaviors and pain-killing effects following spinal injections of morphine. All of the mice got relief from a mildly painful stimulus, but those without the GRPR gene did not scratch.

Next they studied normal mice treated with a small peptide that interferes with GRPR function. When injected with the GRPR blocker, mice still got morphine's pain-killing benefits, but they did not itch.

"If we inject a GRPR inhibitor and morphine into the mouse spinal cord, the drug still has its normal analgesic effect, but the mice don't scratch," Chen says. "This is very interesting because it demonstrates that analgesia and itching can be separated. There may be itch-specific genetic pathways in the spinal cord that are not related to pain sensation."

This result contrasts with a previous finding from Chen's team. In prior studies when GRPR mutant mice were compared to normal, control mice, they demonstrated significantly decreased scratching behavior in response to itchy stimuli, but they still scratched a little. In this study, however, morphine-induced scratching behavior was completely eliminated in GRPR mutant mice, suggesting GRPR is essential in transmitting itching induced by opioids.

Chen says this genetic pathway for itch sensation seems to be conserved in all mammals. Like mice, humans also have GRPR genes, so he believes it may be possible to treat chronic itching in humans with a similar strategy. Those people, he says, would continue to get pain relief from drugs such as morphine, but they would not feel as itchy after receiving the drug.

"Our findings could have important therapeutic implications," Chen says. "More research needs to be done, but it may be possible to relieve itching in patients by blocking GRPR function without affecting the pain pathway."

Chen ZF, Molecular mechanisms of itch in the spinal cord. Abstract for Neuroscience 2008. Presented on Nov. 17, 2008.

Related paper: Sun YG, Chen ZF. A gastrin-releasing peptide receptor mediates the itch sensation in the spinal cord. Nature (448), pp. 700-703. Aug. 9,2007 (published online July 25,2007). doi:10.1038/nature06029.

Funding from the National Institutes of Health supported this research.

Can Cherries Relieve The Pain Of Osteoarthritis?

For the estimated 27 million Americans who suffer from osteoarthritis, pain relief may come with a cherry on top. According to researchers with the Baylor Research Institute, tart cherries, in pill form, may be a promising pain-reliever for this common and debilitating form of arthritis.

More than half of the patients enrolled in a 2007 pilot study at the Baylor Research Institute experienced a significant improvement in pain and function after taking the cherry pills for eight weeks. Osteoarthritis, the most common type of arthritis, is considered degenerative and typically affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Patients with osteoarthritis of the knees were enrolled in this pilot study to assess potential efficacy of the tart cherry pills.

“The current treatment of osteoarthritis is largely focused on controlling pain through use of over-the-counter acetaminophen or prescription pain medications as well as non-steroidal anti-inflammatory drugs,” explains John J. Cush, M.D., rheumatologist and principal investigator of the study. “These conventional medications are widely used, but have not been shown to alter the natural history of the disease. In some cases, overuse may contribute to significant gastrointestinal, cardiovascular, hematologic, renal and liver toxicity.”

Made from Montmorency tart cherries, this preparation is made up of ground whole cherries and given as a soft gelatin capsule (marketed under the brand name CherryFlex®).

“This specific type of tart cherry is one of the best studied natural products and anecdotally has been claimed to have a salutary effect on osteoarthritis and other types of arthritis as well,” adds Dr. Cush.

Baylor Research Institute together with the Arthritis Care & Research Institute is currently enrolling patients in a second study, which will test cherry pills versus placebo in an eight week double blind study.

Chronic Pain Harms The Brain

People with unrelenting pain don't only suffer from the non-stop sensation of throbbing pain. They also have trouble sleeping, are often depressed, anxious and even have difficulty making simple decisions.

In a new study, investigators at Northwestern University's Feinberg School of Medicine have identified a clue that may explain how suffering long-term pain could trigger these other pain-related symptoms.

Researchers found that in a healthy brain all the regions exist in a state of equilibrium. When one region is active, the others quiet down. But in people with chronic pain, a front region of the cortex mostly associated with emotion "never shuts up," said Dante Chialvo, lead author and associate research professor of physiology at the Feinberg School. "The areas that are affected fail to deactivate when they should."

They are stuck on full throttle, wearing out neurons and altering their connections to each other.

This is the first demonstration of brain disturbances in chronic pain patients not directly related to the sensation of pain.

Chialvo and colleagues used functional magnetic resonance imaging (fMRI) to scan the brains of people with chronic low back pain and a group of pain-free volunteers while both groups were tracking a moving bar on a computer screen. The study showed the pain sufferers performed the task well but "at the expense of using their brain differently than the pain-free group," Chialvo said.

When certain parts of the cortex were activated in the pain-free group, some others were deactivated, maintaining a cooperative equilibrium between the regions. This equilibrium also is known as the resting state network of the brain. In the chronic pain group, however, one of the nodes of this network did not quiet down as it did in the pain-free subjects.

This constant firing of neurons in these regions of the brain could cause permanent damage, Chialvo said. "We know when neurons fire too much they may change their connections with other neurons and or even die because they can't sustain high activity for so long," he explained.

'If you are a chronic pain patient, you have pain 24 hours a day, seven days a week, every minute of your life," Chialvo said. "That permanent perception of pain in your brain makes these areas in your brain continuously active. This continuous dysfunction in the equilibrium of the brain can change the wiring forever and could hurt the brain."

Chialvo hypothesized the subsequent changes in wiring "may make it harder for you to make a decision or be in a good mood to get up in the morning. It could be that pain produces depression and the other reported abnormalities because it disturbs the balance of the brain as a whole."

He said his findings show it is essential to study new approaches to treat patients not just to control their pain but also to evaluate and prevent the dysfunction that may be generated in the brain by the chronic pain.

The study will be published Feb. 6 in The Journal of Neuroscience. Chialvo's collaborators in this project are Marwan Baliki, a graduate student; Paul Geha, a post-doctoral fellow, and Vania Apkarian, professor of physiology and of anesthesiology, all at the Feinberg School.

Pain Is Not A Symptom Of Arthritis, Pain Causes Arthritis, Study Shows

Pain is more than a symptom of osteoarthritis, it is an inherent and damaging part of the disease itself, according to a study just published in journal Arthritis and Rheumatism. More specifically, the study revealed that pain signals originating in arthritic joints, and the biochemical processing of those signals as they reach the spinal cord, worsen and expand arthritis.

In addition, researchers found that nerve pathways carrying pain signals transfer inflammation from arthritic joints to the spine and back again, causing disease at both ends.

Technically, pain is a patient's conscious realization of discomfort. Before that can happen, however, information must be carried along nerve cell pathways from say an injured knee to the pain processing centers in dorsal horns of the spinal cord, a process called nociception. The current study provides strong evidence that two-way, nociceptive "crosstalk" may first enable joint arthritis to transmit inflammation into the spinal cord and brain, and then to spread through the central nervous system (CNS) from one joint to another.

Furthermore, if joint arthritis can cause neuro-inflammation, it could have a role in conditions like Alzheimer's disease, dementia and multiple sclerosis. Armed with the results, researchers have identified likely drug targets that could interfere with key inflammatory receptors on sensory nerve cells as a new way to treat osteoarthritis (OA), which destroys joint cartilage in 21 million Americans. The most common form of arthritis, OA eventually brings deformity and severe pain as patients loose the protective cushion between bones in weight-bearing joints like knees and hips.

"Until relatively recently, osteoarthritis was believed to be due solely to wear and tear, and inevitable part of aging," said Stephanos Kyrkanides, D.D.S., Ph.D., associate professor of Dentistry at the University of Rochester Medical Center. "Recent studies have revealed, however, that specific biochemical changes contribute to the disease, changes that might be reversed by precision-designed drugs. Our study provides the first solid proof that some of those changes are related to pain processing, and suggests the mechanisms behind the effect," said Kyrkanides, whose work on genetics in dentistry led to broader applications. The common ground between arthritis and dentistry: the jaw joint is a common site of arthritic pain.

Study Details

Past studies have shown that specific nerve pathways along which pain signals travel repeatedly become more sensitive to pain signals with each use. This may be a part of ancient survival skill (if that hurt once, don't do it again). Secondly, pain has long been associated with inflammation (swelling and fever).

In fact, past research has shown that the same chemicals that cause inflammation also cause the sensation of pain and hyper-sensitivity to pain if injected. Kyrkanides' work centers around one such pro-inflammatory, signaling chemical called Interleukin 1-beta (IL-1β), which helps to ramp up the bodies attack on an infection.

Specifically, Kyrkanides' team genetically engineered a mouse where they could turn up on command the production of IL-1β in the jaw joint, a common site of arthritis. Experiments showed for the first time that turning up IL-1β in a peripheral joint caused higher levels of IL-1β to be produced in the dorsal horns of the spinal cord as well.

Using a second, even more elaborately engineered mouse model, the team also demonstrated for the first time that creating higher levels of IL-1β in cells called astrocytes in the spinal cord caused more osteoarthritic symptoms in joints. Past studies had shown astrocytes, non-nerve cells (glia) in the central nervous system that provide support for the spinal cord and brain, also serve as the immune cells of CNS organs. Among other things, they release cytokines like IL-1β to fight disease when triggered. The same cytokines released from CNS glia may also be released from neurons in joints, possibly explaining how crosstalk carries pain, inflammation and hyper-sensitivity back and forth.

In both mouse models, experimental techniques that shut down IL-1β signaling reversed the crosstalk effects. Specifically, researchers used a molecule, IL-1RA, known to inhibit the ability of IL-1β to link up with its receptors on nerve cells. Existing drugs (e.g. Kineret® (anakinra), made by Amgen and indicated for rheumatoid arthritis) act like IL-1RA to block the ability IL-1β to send a pain signal through its specific nerve cell receptor, and Kyrkanides' group is exploring a new use for them as osteoarthritis treatment.

The implications of this process go further, however, because the cells surrounding sensory nerve cell pathways too can be affected by crosstalk. If 10 astrocytes secrete IL-1β in response to a pain impulse, Kyrkanides said, perhaps 1,000 adjacent cells will be affected, greatly expanding the field of inflammation. Spinal cord astrocytes are surrounded by sensory nerve cells that connect to other areas of the periphery, further expanding the effect. According to Kyrkanides' model, increased inflammation by in the central nervous system can then send signals back down the nerve pathways to the joints, causing the release of inflammatory factors there.

Among the proposed, inflammatory factors is calcitonin gene related peptide (CGRP). The team observed higher levels calcitonin-gene related peptide (CGRP) production in primary sensory fibers in the same regions where IL-1β levels rose, and the release of IL-1β by sensory neurons may cause the release of CGRP in joints. Past studies in Kyrkanides reveal that CGRP can also cause cartilage-producing cells (chondrocytes) to mature too quickly and die, a hallmark of osteoarthritis.

Joining Kyrkanides in the publication from the University of Rochester School of Medicine and Dentistry were co-authors M. Kerry O'Banion, M.D., Ph.D., Ross Tallents, D.D.S., J. Edward Puzas, Ph.D. and Sabine M. Brouxhon, M.D. Paolo Fiorentino was a student contributor and Jennie Miller was involved as Kyrkanides' technical associate. Maria Piancino, led a collaborative effort at the University of Torino, Italy. This work was supported in part by grants from the National Institutes of Health.

"Our study results confirm that joints can export inflammation in the form of higher IL-1β along sensory nerve pathways to the spinal cord, and that higher IL-1β inflammation in the spinal cord is sufficient in itself to create osteoarthritis in peripheral joints," Kyrkanides said. "We believe this to be a vitally important process contributing to orthopaedic and neurological diseases in which inflammation is a factor."

Pain Is In The Eye Of The Beholder

By manipulating the appearance of a chronically achy hand, researchers have found they could increase or decrease the pain and swelling in patients moving their symptomatic limbs. The findings— reported in the November 25th issue of Current Biology — reveal a profound top-down effect of body image on body tissues, according to the researchers.The brain is capable of many wonderful things based on its perception of how the body is doing and the risks to which the body seems to be exposed," said G. Lorimer Moseley, who is now at the Prince of Wales Medical Research Institute in Australia. (The work was done at the University of Oxford.)

In the study, the researchers asked ten right-handed patients with chronic pain and dysfunction in one arm to watch their own arm while they performed a standardized set of ten hand movements. The participants repeated the movements under four conditions: with no visual manipulation, while looking through binoculars with no magnification, while looking through binoculars that doubled the apparent size of their arm, and while looking through inverted binoculars that reduced the apparent size of their arm.

While the patients' pain was always worse after movement than it was before, the extent to which the pain worsened depended on what people saw. Specifically, the pain increased more when participants viewed a magnified image of their arm during the movements, and—perhaps more surprisingly—the pain became less when their arm was seen through inverted binoculars that minimized its size.

The degree of swelling too was less when people watched a "minified" image of their arm during movements than when they watched a magnified or normal image, the researchers reported.

They aren't yet sure how this phenomenon works at the level of neurons. However, the researchers said, a possible philosophical explanation comes from the notion that protective responses—including the experience of pain—are activated according to the brain's implicit perception of danger level. "If it looks bigger, it looks sorer and more swollen," Moseley said. "Therefore, the brain acts to protect it."

While he said the findings don't mean that pain is any less real, they may lead to a new therapeutic approach for reducing pain. His team is now testing visual manipulations as an analgesic strategy for use in clinical settings.

The researchers include G. Lorimer Moseley, University of Oxford, UK, Prince of Wales Medical Research Institute, Sydney, Australia; Timothy J. Parsons, University of Oxford, UK; and Charles Spence, University of Oxford, UK.

Baffling Chronic Pain Linked To Weird Rewiring Of Brain

Scientists peered at the brains of people with a baffling chronic pain condition and discovered something surprising. Their brains looked like an inept cable guy had changed the hookups, rewiring the areas related to emotion, pain perception and the temperature of their skin.

The new finding by scientists at Northwestern University's Feinberg School of Medicine, begins to explain a mysterious condition that the medical community had doubted was real.

The people whose brains were examined have a chronic pain condition called complex region pain syndrome (CRPS.) It's a pernicious and nasty condition that usually begins with an injury causing significant damage to the hand or the foot. For the majority of people, the pain from the injury disappears once the limb is healed. But for 5 percent of the patients, the pain rages on long past the healing, sometimes for the rest of people's lives. About 200,00 people in the U.S. have this condition.

In a hand injury, for example, the pain may radiate from the initial injury site and spread to the whole arm or even the entire body. People also experience changes in skin color to blue or red as well as skin temperature (hotter at first, then becoming colder as the condition turns chronic.) Their immune system also shifts into overdrive, indicated by a hike in blood immune markers.

The changes in the brain take place in the network of tiny, white "cables" that dispatch messages between the neurons. This is called the brain's white matter. Several years ago, Northwestern researchers discovered chronic pain caused the regions in the brain that contain the neurons -- called gray matter because of it looks gray -- to atrophy.

This is the first study to link pain with changes in the brain's white matter. It will be published November 26 in the journal Neuron.

"This is the first evidence of brain abnormality in these patients," said A. Vania Apkarian, professor of physiology at the Feinberg School and principal investigator of the study. " People didn't believe these patients. This is the first proof that there is a biological underpinning for the condition. Scientists have been trying to understand this baffling condition for a long time."

Apkarian said people with CRPS suffer intensely and have a high rate of suicide. "Physicians don't know what to do," he said. "We don't have the tools to take care of them."

The new findings provide anatomical targets for scientists, who can now look for potential pharmaceutical treatments to help these patients, Apkarian said. He doesn't know yet if chronic pain causes these changes in the brain or if CRPS patients' brains have pre-existing abnormalities that predispose them to this condition.

In the new study, the brains of 22 subjects with CRPS and 22 normal subjects were examined with an anatomical MRI and a diffusion tensor MRI, which enabled scientists to view the white matter. In addition to changes in white matter, the CRPS patients' brains showed an atrophy of neurons or gray matter similar to what has been previously shown in other types of chronic pain patients.

Apkarian said the white matter changes in patients' brains is related to the duration and intensity of their pain and their anxiety. It is likely that white matter reorganizes in other chronic pain conditions as well, but that has not yet been studied, he noted.

Pain Research Funding Declines Sharply At NIH

Federal funding for pain research is declining sharply, more than 9 percent a year since 2003, according to a new study published in The Journal of Pain. Pain research, as a result, now accounts for only 0.6 percent of all grants awarded by the National Institutes of Health (NIH), despite the high prevalence of chronic pain in the U.S.

"This startling finding shows the government's meager investment in pain research is seriously out of proportion with the widespread chronic pain incidence in our society, which is estimated at one in four Americans and accounts for more than 20 percent of all physician office visits," said Charles E. Inturrisi, president of the American Pain Society and professor of pharmacology at Weill Cornell Medical College, New York. "And this disparity is not attributable to years of budget cuts at NIH because the Journal of Pain study clearly shows pain research has a higher percentage decline than the overall NIH budget. So the drop in agency funding has not affected all research areas equally."

University of Utah researchers led by David H. Bradshaw, PhD of the university's pain research center, analyzed data about NIH grant awards from 2003 through 2007 for pain and compared pain research funding with dollars allocated for nausea and dyspnea, a breathing disorder. A previous study authored by Bradshaw, also published in The Journal of Pain in 2005, found that less than one percent of all NIH funding in 2003 was for research having a primary emphasis on pain. The current study shows that five years later pain research is still a low priority at NIH.

Noting that overall budget pressures in Washington have led to an unprecedented recession in funding for biomedical research, the authors said: "With decreased funding for research and continuing needs for resources to support national security and military efforts, major natural disasters and uncertain economic status, competition for limited research funds will intensify. The ability to track funding patterns becomes increasingly important for policy making decisions."

Inturrisi said APS has given financial support for the group's ongoing monitoring of NIH funding for pain research. "Our goal is to provide policy makers with an objective and verifiable classification tool for measuring grant awards and funding trends to help determine if NIH research dollars are being directed where the scientific and clinical need is most compelling," said Inturrisi. "Untreated and undertreated pain is the nation's most pervasive health problem and it's getting worse as the population ages. Pain research is the key for learning more about pain mechanisms and possible new treatments, but it is difficult to make significant progress if pain studies comprise just half of one percent of all NIH research grants," he added.

The study also reported that a review of all records for primary research for nausea and dyspnea, revealed that, unlike pain research funding trends, grants for those conditions increased steadily from 2003 to 2007. The authors concluded that even though there have been unprecedented funding cuts at NIH, "additional measures should be taken at NIH to improve the chances of funding for meritorious applications proposing research on pain."

New Treatment Eliminates Heel Pain Caused By Plantar Fasciitis

Combining an ultrasound-guided technique with steroid injection is 95 percent effective at relieving the common and painful foot problem called plantar fasciitis, according to a study presented today at the annual meeting of the Radiological Society of North America (RSNA).There is no widely accepted therapy or standard of care for patients when first-line treatments fail to relieve the pain of plantar fasciitis," said the study's lead author, Luca M. Sconfienza, M.D., from Italy's University of Genoa. "Our new technique is an effective, one-time outpatient procedure."

Plantar fasciitis, the most common cause of heel pain, is an inflammation of the connective tissue called the plantar fascia that runs along the bottom of the foot, from the heel to the ball of the foot. The condition accounts for 11 percent to 15 percent of all foot symptoms requiring professional care and affects one million people annually in the U.S.

Conservative treatments, which may take up to a year to be effective, include rest, exercises to stretch the fascia, night splints and arch supports.

When the condition does not respond to conservative treatments, patients may opt for shockwave therapy, in which sound waves are directed at the area of heel pain to stimulate healing. Shockwave therapy is painful, requires multiple treatments and is not always effective. Complications may include bruising, swelling, pain, numbness or tingling and rupture of the plantar fascia. In the most severe cases of plantar fasciitis, patients may undergo invasive surgery to detach the fascia from the heel bone.

For this study, Dr. Sconfienza and colleagues used a new ultrasound-guided technique, along with steroid injection, on 44 patients with plantar fasciitis that was unresponsive to conservative treatments.

After injection of a small amount of anesthesia, the anesthetic needle is used to repeatedly puncture the site where the patient feels the pain. This technique is known as dry-needling. Dry-needling creates a small amount of local bleeding that helps to heal the fasciitis. Lastly, a steroid is injected around the fascia to eliminate the inflammation and pain. The technique is performed with ultrasound guidance to improve accuracy and to avoid injecting the steroids directly into the plantar fascia, which could result in rupture.

After the 15-minute procedure, symptoms disappeared for 42 of the study's 44 patients (95 percent) within three weeks.

"This therapy is quicker, easier, less painful and less expensive than shockwave therapy," Dr. Sconfienza said. "In cases of mild plantar fasciitis, patients should first try noninvasive solutions before any other treatments. But when pain becomes annoying and affects the activities of daily living, dry-needling with steroid injection is a viable option."

Co-authors are Francesca Lacelli, M.D., Giovanni Serafini, M.D., Giacomo Garlaschi, M.D., and Enzo Silvestri, M.D.

Physical Therapy Offers Evidence-based Solution To Musculoskeletal Pain

The American Physical Therapy Association (APTA) is urging patients with musculoskeletal pain to consider treatment by a physical therapist, in light of a new federal survey showing that more than one-third of American adults and nearly 12 percent of children use alternative medicine - with back and neck pain being the top reasons for treatment.

Results of the 2007 survey of more than 32,000 Americans were released December 11 by the National Institutes of Health's National Center for Complementary and Alternative Medicine.

According to APTA, physical therapy offers an evidence-based, time-tested solution to these common conditions in comparison to alternative treatments.

For neck pain, for example, a recent study published in the medical journal Spine found that when patients received up to six treatments of manual physical therapy and exercise, they not only experienced pain relief, but were also less likely to seek additional medical care up to one year following treatment.

"This study, demonstrating the efficacy of physical therapy for a condition as widespread as neck pain, is particularly relevant in today's challenging economic environment," according to the study's lead researcher and APTA spokesman Michael Walker, PT, DSc, OCS, CSCS, FAAOMPT. "The Kaiser Foundation, for instance, recently found that more than half of all Americans are not taking prescribed medication and postponing needed medical care in an effort to save money. It is important for consumers to know that there are effective, conservative solutions such as physical therapy available."

Walker's study compared the effectiveness of a three-week program of manual physical therapy and exercise to a minimal intervention treatment approach for patients with neck pain.

Study participants consisted of 94 patients with a primary complaint of neck pain, 58 (62%) of whom also had radiating arm pain. Patients randomized to the manual physical therapy and exercise group received joint and soft-tissue mobilizations and manipulations to restore motion and decrease pain, followed by a standard home exercise program of chin tucks, neck strengthening, and range-of-motion exercises. Patients in the minimal intervention group received treatment consistent with the current guidelines of advice, range-of-motion exercise, and any medication use prescribed by their general practitioner. Patients did not have to complete all six visits if their symptoms were fully resolved.

Sample exercises to relieve neck pain can be found on the APTA

Results show that manual physical therapy and exercise was significantly more effective in reducing mechanical neck pain and disability and increasing patient-perceived improvements during short- and long-term follow-ups. These results are comparable with previous studies that found manual physical therapy and exercise provided greater treatment effectiveness (Hoving et al, 2002) and cost effectiveness (Kothals-de Bos et al, 2003) than general practitioner care.

Use Weights, Not Aerobics, To Ease Back Pain, Study Suggests

People who use weight training to ease their lower back pain are better off than those who choose other forms of exercise such as jogging, according to a University of Alberta study.

The study, done in conjunction with the University of Regina, showed a 60 per cent improvement in pain and function levels for people with chronic backache who took part in a 16-week exercise program of resistance training using dumbbells, barbells and other load-bearing exercise equipment.

In contrast, people who chose aerobic training such as jogging, walking on a treadmill or using an elliptical machine to ease their back pain only experienced a 12 per cent improvement, said Robert Kell, an assistant professor of exercise physiology at the University of Alberta, Augustana Campus.

The resistance-training group showed improvements in pain and function of about 60 per cent, while those who took aerobic training experienced only a 12 per cent improvement.

"Any activity that makes you feel better is something you should pursue, but the research indicates that we get better pain management results from resistance training." The extra benefits stem from using the whole-body approach required in resistance training, Kell believes. "We tried to strengthen the entire body and by doing that, we decreased the fatigue people felt throughout the day. They were better able to perform their activities of daily living." Aerobics training generally works just the lower body, he added.

Approximately 80 per cent of North Americans suffer from lower back pain at some point in their lifetimes, and for 85 per cent of them the pain is chronic.

Both types of training did provide other fitness benefits, such as lower body fat, the study showed.

The findings are to be published in early 2009 in the Journal of Strength and Conditioning Research.

Pain Hurts More If Person Hurting You Means It

Researchers at Harvard University have discovered that our experience of pain depends on whether we think someone caused the pain intentionally. In their study, participants who believed they were getting an electrical shock from another person on purpose, rather than accidentally, rated the very same shock as more painful. Participants seemed to get used to shocks that were delivered unintentionally, but those given on purpose had a fresh sting every time.

The research, published in the current issue of Psychological Science, was led by Kurt Gray, a graduate student in psychology, along with Daniel Wegner, professor of psychology.

It has long been known that our own mental states can alter the experience of pain, but these findings suggest that our perceptions of the mental states of others can also influence how we feel pain.

"This study shows that even if two harmful events are physically identical, the one delivered with the intention to hurt actually hurts more," says Gray. "Compare a slap from a friend as she tries to save us from a mosquito versus the same slap from a jilted lover. The first we shrug off instantly, while the second stings our cheek for the rest of the night."

The study's authors suggest that intended and unintended harm cause different amounts of pain because they differ in meaning.

"From decoding language to understanding gestures, the mind distills meaning from our social environment," says Gray. "An intended harm has a very different meaning than an accidental harm."

The study included 48 participants who were paired up with a partner who could administer to them either an audible tone or an electric shock. In the intentional condition, participants were shocked when their partner chose the shock option. In the unintentional condition, participants were shocked when their partner chose the tone option. Thus, in this condition, they only received a shock when their partner did not intend them to receive one. The computer display ensured that participants both knew their partner's choice and that a shock would be coming, to ensure the shock was not more surprising in the unintentional condition.

Despite identical shock voltage between conditions, those in the intentional condition rated the shocks as significantly more painful. Furthermore, those in the unintentional condition habituated to the pain, rating them as decreasingly painful, while those in the intentional condition continued to feel the full sting of pain.

Gray suggests that it may be evolutionarily adaptive for this difference in meaning to be represented as different amounts of pain.

"The more something hurts, the more likely we are to take notice and stop whatever is hurting us," he says. "If it's an accidental harm, chances are it's a one-time thing, and there's no need to do anything about it. If it's an intentional harm, however, it may be the first of many, so it's good to take notice and do something about it. It makes sense that our bodies and brains might amplify our experience of pain when we know that the pain could signal threats to our survival."

These findings speak to how people experience pain and negative life events. If negative events are seen as intended, they may hurt more. This helps to explain why torture is so excruciating – not only are torture techniques themselves exceptionally painful, but it's the thought that counts—and makes torture hurt more than mere pain.

On the other hand, if negative events are seen as unintended, they may hurt less. This may explain, in part, why people in abusive relationships sometimes continue to stay in them. By rationalizing that an abusive partner did not intend harm, some victims may reduce their experience of pain, which could make them less likely to leave the relationship and escape the abuse.

The research was supported by the National Institute of Mental Health, the Canadian Social Sciences and Humanities Research Council and the Institute for Humane Studies.

Lumbar Fusion Has Long-term Benefits, Study Suggests

Lumbar fusion is becoming an increasingly common treatment for low-back pain, but its long-term effects are relatively unknown. A doctoral thesis from the Swedish medical university Karolinska Institutet now shows that the long-term effects are superior to those of physiotherapy.

Chronic low-back pain is treated increasingly often with lumbar fusion, by which several lower back vertebrae are fused in a way that has little impact on the back’s overall mobility. Lumbar fusion has been shown to relieve pain in the short term, but no studies have examined the long-term effects of the operation and compared them with alternative, non-surgical treatments like physiotherapy.

Per Ekman is a surgeon at Stockholm South General Hospital (Södersjukhuset), and has shown in his doctoral thesis that patients who have undergone lumbar fusion also improve in the longer term. His results are based on an evaluation of 111 patients, randomly assigned treatment with lumbar fusion or physiotherapy. On a follow-up nine years later, 76 per cent of the surgical group stated that they felt better than before the operation, compared with only 50 per cent of the physiotherapy group.

“Whether lumbar fusion should be used at all for this type of back pain has long been the subject of much debate,” says Dr Ekman. “My studies suggest that most patients who have undergone lumbar fusion actually feel better, and that the operation carries no great risk. However, long-term improvements are often relatively modest, and the operation should also continue to be used as a complement to physiotherapy when this treatment doesn’t help.”

His thesis shows that men, the physically active and the gainfully employed have somewhat higher chances of benefitting from the operation than others.

“This tells us something, but unfortunately there are still no good methods for finding those with the best chances of responding well to the operation,” says Dr Ekman.

Thesis: Lumbar fusion for chronic low-back pain in isthmic spondylolisthesis, Per Ekman, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet.

Premature Babies Have Altered Sensory Responses In Later Life

Premature infants who need intensive care or surgery are less sensitive to thermal (hot and cold) sensations later in life, according to research conducted at UCL (University College London). The study, published in the journal Pain, suggests that pain and injury related to major medical interventions in early development may alter how children respond to painful stimuli much later in life.

In the study, 43 eleven-year-old children born at less than 26 weeks of gestation (14 weeks premature) who are being followed up by the EPICure study group, were tested for their responses to different sensations – temperature and light touch – using quantitative sensory testing. Compared to a group of children who had been born at full term, the premature children were less sensitive to temperature (cool, cold, warm and hot) but not to light touch, and this was most marked in those who had also undergone a surgical operation as a baby.

The researchers also found a more marked decrease in sensitivity to temperature and to touch close to scars relating to major chest surgery, again suggesting that the severity of injury in early life influences the degree of sensory change. A questionnaire survey showed that the children's everyday pain experiences were similar, but there were some minor differences between the two groups in the way children coped with pain.

Dr Suellen Walker, UCL Institute of Child Health, says: "Our study shows that babies who are born premature and need intensive care or surgery develop long-term changes in their responses to hot and cold sensations. As the same nerve fibres transmit temperature and pain, changes in thermal sensitivity may also be associated with altered responses to pain in later life. In our laboratory studies, we have also shown that surgical incisions in early life reduce sensitivity to temperature and pressure, and alter pain responses to future surgery. These effects appear to be specific to early life, as seen in the premature children who were operated on as babies."

"The pain mechanisms in our bodies are plastic – that is, injury and nerve activity can alter them, but this is particularly true in early life when the nervous system is still developing. Our research aims to understand how responses to injury change, and how best to treat pain, at different stages of development. We are currently testing different types and doses of analgesics to prevent the long-term changes we have discovered, and this will help doctors to choose the most effective painkillers for preterm babies."

Professor Neil Marlow, UCL Elizabeth Garrett Anderson Institute for Women's Health, says: "The rate of preterm birth is rising, and improvements in intensive care mean that babies are surviving from very young gestational ages. Many of the procedures necessary to monitor and treat such babies are painful and even in the most premature babies, can trigger responses in pain-sensing areas of the brain. In some cases, major surgery may be needed to treat complications of prematurity or to correct congenital defects. It is therefore important for us to understand not only how these interventions at the earliest stages of development may affect the body's sensory functions later in life, but also how we can minimise exposure to painful stimuli."

Cost Effectiveness Of Spinal Surgery Analyzed

Back pain affects more than 80 percent of people and costs more than $100 billion annually in the U.S. But is the surgery cost effective? A study by researchers at Rush University Medical Center suggests that for patients with spinal stenosis, a laminectomy, or surgical removal of some soft bone and tissue, is a reasonable value. However, for patients with spinal stenosis with associated slipped vertebrae, the benefits of spinal fusion surgery may not be enough to offset costs.

The study is published in the December 16 issue of the Annals of Internal Medicine.

Rush was one of 13 sites throughout the country and the only Chicago site that followed patients in the Spine Patient Outcomes Research Trial (SPORT).

“This study is significant because it is the first to systematically track people’s health care expenditures and health outcomes,” said Dr. Gunnar Andersson, former chairman of the department of Orthopedics at Rush and study investigator. “More than 650,000 surgical procedures are performed annually for back pain in the United States with costs exceeding $20 billion. Whether this investment provides good value is largely unknown.”

The study looked at two conditions, spinal stenosis that is treated most commonly with laminectomy, which is a procedure where orthopedic surgeons remove the portion of the vertebral bone called the lamina and soft tissue to relieve pressure on the nerves in the spine. The second condition that was analyzed is spinal stenosis with slipped vertebrae also known as spinal stenosis with degenerative spondylolisthesis, which is most commonly treated with spine fusion surgery.

More than 3,900 patients participated in the randomized, controlled trial of surgery versus non-operative treatment. 320 patients underwent laminectomy and 344 patients had spinal fusion.

Researchers used the Quality Adjusted Life Year (QALY) scale to measure benefit to patients in comparison to the direct and indirect costs of the surgical procedures over a two-year period after surgery. The researchers calculate that stenosis surgery using laminectomy cost is $77,000 per QALY gained. In contrast, spinal fusion surgery for stenosis with slipped vertebrae cost about $115,000 per QALY gained. In the U.S., $100,000 is the threshold at which procedures are considered to be cost effective.

The initial two-year analysis indicates that decompressive surgery without fusion for spinal stenosis offers good value and that fusion surgery for spondylolithesis offers less value for its cost than most accepted interventions. A definitive assessment of cost effectiveness awaits longer term outcome data, which will be analyzed further as the trial continues.

“With the number of spine surgery cases in the U.S. increasing and the rising costs of health care expenditures, it is extremely important for us to understand the economic value of common surgical procedures,” said Andersson. “Cost effectiveness is a critical component of providing patients with quality care.”

“With the SPORT trial we have an innovative and collaborative multicenter study of elective orthopedic interventions,” said Andersson. “As we continue to analyze the outcomes of these procedures over the next decade, we will have more long-term results that will benefit back pain patients.”

“For many patients suffering from back pain, getting rid of the pain is worth any cost,” said Andersson.

Nerve Cells In The Brain And Spinal Cord Sense Pain Caused By Physical Insult

Researchers have shown that the protein COX2 in mouse nerve cells in the central nervous system (CNS) is crucial for hypersensitivity to pain caused by the physical insult associated with inflammation, but not pain caused by the heat associated with inflammation. As pain caused by physical insult is a major symptom of postoperative and arthritic inflammation, it seems that COX2 in nerve cells in the CNS is central to the pain that accompanies these conditions.

The most common way of managing the pain that accompanies inflammation is to use drugs such as aspirin and ibuprofen.

These work by selectively blocking the protein COX2, which functions to produce soluble molecules known as prostaglandins. Although it is known that blocking COX2 in the tissue and in the brain and spinal cord (the CNS) reduces the pain that accompanies inflammation, the relative contribution of COX2 at these two sites to the pain that accompanies inflammation has not been determined.

However, a team of researchers, at Massachusetts General Hospital, Boston, and University of Pennsylvania, Philadelphia, have now shown that COX2 in mouse nerve cells in the CNS is crucial for some forms of pain associated with inflammation but not others. Specifically, hypersensitivity to pain caused by the heat associated with inflammation was normal in mice lacking COX2 in nerve cells in the CNS.

By contrast, hypersensitivity to pain caused by the physical insult associated with inflammation was abolished in these mice. As pain caused by physical insult is a major symptom of postoperative and arthritic inflammation, it seems that COX2 in nerve cells in the CNS is central to the pain that accompanies these conditions.

Antioxidants Offer Pain Relief In Patients With Chronic Pancreatitis

Antioxidant supplementation was found to be effective in relieving pain and reducing levels of oxidative stress in patients with chronic pancreatitis (CP), reports a new study in Gastroenterology. CP is a progressive inflammatory disease of the pancreas in which patients experience abdominal pain (in early stage) and diabetes and maldigestion (in late stage).

Pain is the major problem in 90 percent of patients with CP and currently, there is no effective medical therapy for pain relief. Gastroenterology is the official journal of the American Gastroenterological Association (AGA) Institute.

In this placebo-controlled, double blind trial, 127 patients, ages 30.5+/-10.5, were assigned to placebo or antioxidant groups. After six months, the reduction in the number of painful days/month was significantly higher in the antioxidant group, compared with the placebo group (7.4±6.8 versus 3.2±4, respectively). The reduction in the number of analgesic tablets/month was also higher in the antioxidant group (10.5±11.8 versus 4.4±5.8, respectively). Furthermore, 32 percent and 13 percent of patients became pain free in the antioxidant and placebo groups, respectively; the beneficial effect of antioxidants on pain relief was noted early at three months.

"Abdominal pain, the predominant symptom in patients with CP, is difficult to treat. The main reason for a largely ineffective medical treatment is that the mechanism of pain in CP is not well understood," said Pramod Kumar Garg, MD, DM, of the All India Institute of Medical Sciences, New Delhi and lead author of the study. "We are encouraged by our findings, as significant improvement was noted with antioxidants in respect to all the parameters of pain in this study. In addition, reduction in pain resulted in fewer man-days lost, thus providing functional employment gain to the patients. The findings should spur further research in this exciting area."

There are two important implications of this study — the fact that measures of oxidative stress were increased initially and decreased subsequently after supplementation with antioxidants suggests that there is a state of heightened free radical mediated injury in CP, and that injury is reversible. Second, with regard to pain management, this trial showed that antioxidant therapy is effective for pain relief in patients with CP. This assumes significance since no effective medical therapy exists for pain relief for such patients.

Pancreatitis is inflammation of the pancreas that usually begins as a sudden attack and is often caused by gallstones, alcohol abuse or genetic mutations. Symptoms of pancreatitis start with a gradual or sudden severe pain in the center part of the upper abdomen going through to the back. Treatment often focuses on the nutritional and metabolic needs of the patient and on relieving pain. Most people with chronic pancreatitis have a good prognosis if they follow their treatment regimen. "Aside from medication, abstaining from alcohol and smoking are most important and key to halt the progression of CP," added Dr. Garg.

Unique Skeletal Muscle Design Contributes To Spine Stability

The novel design of a deep muscle along the spinal column called the multifidus muscle may in fact be key to spinal support and a healthy back, according to researchers at the University of California, San Diego School of Medicine.

Their findings about the potentially important "scaffolding" role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery.

"The multifidus muscle was formerly thought to be relatively unimportant based on its fairly small size," said Richard L. Lieber, Ph.D., Professor and Vice Chair of UC San Diego's Department of Orthopedic Surgery and Director of the National Center for Skeletal Muscle Rehabilitation Research, based at UC San Diego. Lieber is also Senior Research Career Scientist at the Veterans Affairs San Diego Health System. "Our research shows that it's actually the strongest muscle in the back because of its unique design. It's like a long, skinny pencil packed with millions of tiny fibers."

The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods, and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure muscle internal properties during back surgery, they demonstrated that the multifidus' unique design serves a critical function as a stabilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D., Professor and Chair of UCSD's Department of Orthopaedic Surgery.

"It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes significantly to spinal stabilization," said Garfin. "The more we know about what muscles do, the better we can devise therapeutic interventions such as physical therapy to target specific muscles."

Garfin explained that currently surgery to treat spinal disorders could actually disrupt the multifidus muscle, which could lead to decreased stabilization and lower back pain. Minimally invasive spine surgery techniques strive to minimize surgical trauma to these muscles in order to best preserve their function.

The lower back, or lumbar spine, can be vulnerable to many pain-causing injuries or disorders because the lumbar vertebrae carry the most body weight and are subject to the most force and stress along the spine. Muscular instability is a risk factor in many injuries and consequent chronic lower back pain, according to Lieber.

"The multifidus back muscle keeps us vertical and takes pressure off the discs," said Lieber. "When muscle function is poor due to back problems, support is lost."

He explained that many muscles get weaker as they are extended. But the researchers discovered that, unlike all other muscles, the multifidus actually becomes stronger as it lengthens, when the spine flexes.

"The length of the sarcomere—the structure within the muscle cell where filaments overlap to produce the movements required for muscle contraction—is shorter in the multifidus than in any other muscle cell," explained study's first author Samuel R. Ward, P.T., Ph.D., Assistant Professor of Radiology at UC San Diego School of Medicine. "But as it gets longer, for instance as a person leans forward, the multifidus actually strengthens."

Contributing authors to the study include UCSD researchers Choll W. Kim, M.D., Ph.D., Carolyn M. Eng, B.S., Lionel J. Gottschalk, B.S.; and Akhito Tomiya, M.D., Ph.D. Tohoku University School of Medicine, Sendai, Japan. Research was supported by the Department of Veterans Affairs Rehabilitation, Research and Development; the National Institutes of Health and DePuy Spine of Raynham, MA.

Pain Relieving Effects Of Acupuncture Are Limited

The pain relieving effects of acupuncture compared with placebo are small and seem to lack clinical relevance, according to a study published on the British Medical Journal website.

Researchers at the Nordic Cochrane Centre in Copenhagen analysed evidence from thirteen acupuncture pain trials involving over 3,000 patients. The trials compared three arms of treatment (real acupuncture, placebo or 'pretend' acupuncture or no acupuncture) for a broad range of common conditions such as knee osteoarthritis, migraine, low back pain and post-operative pain.

Before the analysis, differences in study design and quality were taken into account to minimise bias.

They found a small analgesic effect of real acupuncture compared to placebo acupuncture. This corresponded to a reduction in pain levels of about 4mm on a 100mm pain scoring scale. A 10mm reduction on this scale is classed as 'minimal' or 'little change' so the apparent analgesic effect of acupuncture seems to be below a clinically relevant pain improvement, say the authors.

They found a moderate difference between placebo acupuncture and no acupuncture (10mm on a 100mm pain scoring scale), but the effect of placebo acupuncture varied considerably. Some large trials reported effects of placebo that were of clear clinical relevance (24mm), whereas other large trials found effects that seemed clinically irrelevant (5mm).

The authors could not explain this variation, but they did not find an association between the type of placebo acupuncture and its effect.

Our findings correspond with several Cochrane reviews on acupuncture for various types of pain, which all concluded that there was no clear evidence of an analgesic effect of acupuncture, say the authors.

Our findings also question both the traditional foundation of acupuncture and the prevailing theory that acupuncture has important effect on pain in general.

They suggest that future trials focus on reducing bias and trying to separate the physiological effect of using a needle and the psychological impact of the treatment ritual.

In an accompanying editorial, Dr Adrian White and Dr Mike Cummings of the British Medical Acupuncture Society suggest that although the overall effect of acupuncture in relation to usual care is not large, it may be clinically relevant for musculoskeletal conditions, particularly in view of the limited treatment options, and acupuncture's safety record and patient preference.

They believe that future research should focus on comparing acupuncture with best existing treatments for different conditions.

Acupuncture seems, in part at least, to use neurological pathways in common with placebo analgesia and the study of these may offer important insights into improving care, they conclude.

Motor Control Exercises Reduce Persistent Low-back Pain, Study Shows

Motor control exercises, when performed in conjunction with other forms of therapy, can significantly reduce pain and disability in patients with persistent low back pain, according to a new systematic review published in the January issue of Physical Therapy (PTJ), the scientific journal of the American Physical Therapy Association (APTA)

In addition to feeling less pain, patients performing these types of exercises are able to be more physically active and experience positive effects over a longer period of time than those who receive other treatments, according to researchers.

Motor control exercise, also known as specific stabilization exercise, is a new form of exercise for back pain that has gained the attention of researchers and health practitioners over the past decade. The exercise focuses on regaining control of the trunk muscles, also known as the transversus abdominis and multifidus, which support and control the spine. Previous studies of patients with low back pain have shown they are unable to properly control these muscles. Through motor control exercise, patients are taught how to isolate and "switch on" these muscles and then incorporate these movements into their normal activities.

"Although the exercises seemed promising, until now we did not have clear evidence on whether or not they were more effective," according to researcher Luciana G Macedo, PT, MSc, a PhD student at The George Institute for International Health in Sydney, Australia.

"It is important to note that this form of exercise is different from going to the gym or going for a walk," explained Macedo." The program relies upon a skilled clinician, such as a physical therapist, identifying the specific trunk muscles that are a problem and then working closely with patients to teach them how to get the muscles working properly again. The patient first learns to control these muscles in simple postures, then later in more challenging activities. The ultimate goal is for the patient to get the muscles to work to control and support the spine in those activities that previously caused pain."

"Low back pain is an international health problem with enormous economic and social costs," added Macedo. "In America alone, the treatment cost of back pain is estimated to be $86 billion per year or 9% of the country's total health expenditure. The search for new ways to manage this old problem is critical in order to improve the health and quality of life of individuals who struggle with this condition."

The report in PTJ systematically reviewed and then summarized 14 randomized, controlled trials, evaluating the effectiveness of motor control exercises for persistent, low back pain.

Exercise Underutilized For Chronic Back And Neck Pain

Exercise is commonly used to improve physical function, decrease symptoms and minimize disability caused by chronic low back or neck pain. Numerous randomized trials and clinical practice guidelines have supported this practice, and studies suggest that individually tailored, supervised exercise programs are associated with the best outcomes.

Nevertheless, there is a lack of knowledge about exercise prescription, including who is prescribing it, who is getting it and what type of exercise is being prescribed. A new study, funded by the National Institutes of Health, examined these questions and found that exercise may be underutilized for chronic back and neck pain.

Led by Timothy S. Carey and Janet K. Freburger of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, researchers conducted a telephone survey of almost 700 individuals with chronic back or neck pain who saw a physician, chiropractor and/or physical therapist (PT) during the previous 12 months. They asked participants whether they were prescribed exercise, the amount of supervision received, and the type, duration and frequency of the prescribed exercise.

"Less than 50 percent of the subjects in our sample were prescribed exercise, one of the few moderately effective therapies for the highly disabling illness of chronic back and neck pain," the authors state. The type of provider seen played a major role in whether participants received a prescription. Of those who received exercise prescription, 46 percent received the prescription from a PT, 27 percent from a physician, and 21 percent from a chiropractor. The authors note that these findings agree with previous studies that have found that "who you see is what you get."

Although most of the 700 participants had seen a physician, only 14 percent were prescribed exercise. Some of those who were not prescribed exercise by a physician, however, were likely referred to a PT who did prescribe exercise. Not surprisingly, Pts were the most likely to prescribe exercise, although about a third of those who saw a PT did not receive an exercise prescription.

For those who were prescribed exercise, the type of provider seen determined the amount of supervision and, to some extent, the types of exercises prescribed. Pts were more likely to provide supervision and prescribe stretching and strengthening exercises, practices which follow current guidelines and lead to better outcomes.

"Considering current evidence on the efficacy of exercise, these findings demonstrate that exercise is being underutilized as a treatment for chronic back and neck pain," the authors state. They note that none of the hypothesized health-related characteristics, such as pain or weakness in the extremities, hypothesized whether an individual was prescribed exercise and that providers' decisions to prescribe exercise did not appear to be influenced by the degree of impairment. However, women, people with a higher education level and those receiving worker's compensation were more likely to be prescribed exercise. This may be because women and more educated individuals are more likely to be active participants in their care and those with worker's compensation are frequently injured on the job and treated with the goal of returning to work.

"Although exercise prescription provided by Pts appears to be the most in line with current guidelines, there is much room for improvement by all types of providers who prescribe exercise for patients with chronic back and neck pain," the authors note. They suggest that future studies should explore barriers to prescription of exercise treatments, such as practitioner knowledge, organizational aspects of the practice, and poor reimbursement for exercise instruction compared with other types of treatment.

Zen Meditation Alleviates Pain, Study Finds

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

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

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

Meditate away the pain

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

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

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

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

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

This study was funded by the Canadian Institutes of Health Research, the Mind and Life Institute Varela Grant (J.A.G.) and the Fonds de la recherche en santé du Québec.