Findings from a recent study suggest that physicians may be over using narcotics and diagnostic testing for patients that complain of chronic neck pain. Potentially more effective treatments, such as heat treatments and exercise therapy, were often overlooked.
It was found that over half of the participants studied had used or were using strong over-the-counter pain relief for chronic neck pain, despite these types of painkillers having little evidence to support their effectiveness for chronic neck pain.
Researchers from Duke University, NC, USA, and University of North Carolina (UNC), NC, USA, set out to evaluate the prevalence of neck pain sufferers in North Carolina, along with the healthcare used and to compare this to the current evidence indicating the most effective treatments.
The study, published in Arthritis Care & Research, looked at the results of a telephone survey carried out in 5357 households in North Carolina in 2006. The participants were questioned on their health, their healthcare providers and the tests and treatments they had used.
Chronic neck pain was defined as pain that resulted in activity limitations nearly every day for the previous 3 months, or as greater than 24 episodes of pain throughout the previous year that limited activity for one or more days.
The patterns of healthcare recorded for 141 noninstitutionalized adults over the age of 21 years, who reported chronic neck pain, were then compared with the findings and recommendations of current systematic reviews on the subject. The researchers reported that 2.2% of the North Carolina population experienced chronic neck pain. The average duration of chronic pain in the sample population was 6.9 years.
Over 56% of participants in the study used over-the-counter medications (e.g., nonsteroidal anti-inflammatory drugs), 29% reported taking strong narcotics (e.g., MS contin and oxycodone) and 23% used weak narcotics (e.g., codeine and propoxyphene) as treatments for their chronic neck pain. However, systematic reviews, published in The Cochrane Library and The Bone and Joint Decade (BJD) 2000–2010 Task Force on Neck Pain and Its Associated Disorders: Noninvasive Interventions for Neck Pain, provide little medical evidence that this type of pain relief is effective for the ailment.
There is good supporting evidence to suggest that therapeutic exercise is an effective method to provide relief for patients suffering chronic neck pain. However, only 53% of the patients in this study were prescribed exercise therapy.
Approximately 30–50% of the adult population is affected by neck pain in any given year. For approximately 50–58% of these patients the pain they experience in their necks is not easily resolved and can lead to chronic or debilitating pain.
“Our sample population had a high degree of disability, despite using a number of diagnostics and treatments. Based on current evidence, several treatments were over-used, and some effective treatments were under-used,” concluded Adam Goode, UNC Cecil G. Sheps Center for Health Services Research, NC, USA.
Source: Goode AP, Freburger J, Carey T: Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res. 62, 1594–1601 (2010).
Patients taking aromatase inhibitors as a breast cancer treatment can experience debilitating pain in their hands and wrists. A recent study suggests that those patients who have advanced stage breast cancer are the most likely patients to suffer with this pain.
Aromatase inhibitors are prescribed as the standard adjuvant therapy for post-menopausal breast cancer; however, side effects can include severe joint pain in patients, predominantly in the hands and wrists. The pain can be so extreme that up to 15% of patients discontinue medication as a result.
The recent study, presented at the American College of Rheumatology‘s annual meeting in Atlanta, GA, USA, set out to investigate aromatase inhibitor joint pain syndrome further. A total of 35 postmenopausal women were enrolled, all had hormone-sensitive, non-metastasis breast cancer but none showed signs of rheumatic disease.
The patients were followed for 6 months. They were first evaluated at baseline and then at 3 and 6 months after beginning aromatase inhibitor therapy. The evaluation included a physical examination as well as the completion of a questionnaire regarding quality of life, health status and pain. Patients underwent an MRI scan at the time when they complained of pain and also 6 months after beginning aromatase inhibitor treatment.
Out of the 35 patients involved in the study, 19 patients experienced joint pain symptoms and out of these two patients then ceased to adhere to their prescribed medication. A total of 58% of the symptomatic patients experienced pain in their hands.
Although researchers had predicted that the painful syndrome might be caused by an autoimmune condition, this was not found to be the case. The only factor found to predict whether or not the breast cancer patients would experience joint pain was later stage cancer.
“If you have stage II or stage III cancer, you are more likely to have this pain than if you have stage I cancer,” explained Lisa Mandl, Hospital for Special Surgery, NY, USA, who worked on the study. “Before this study, we knew some women got this pain. Now we know that it is more likely in patients with later stage cancer,” Mandl continued.
Source: Hospital for Special Surgery News Network: www.hss.edu/newsroom_aromatase-inhibitor-joint-pain-syndrome.asp
A recent study, which evaluated data from 1389 osteoarthritis (OA) patients (aged 45–79 years), found that patients who experience pain in other joints, such as the lower back, ankle and elbow, were more likely to suffer more severe pain in their knees.
The association between the number and location of pain sites, and severity of knee pain, was studied by Pradeep Suri, Harvard Medical School, New England Baptist Hospital, and Spaulding Rehabilitation Hospital in Boston, MA, USA. The participants were provided by the Osteoarthritis Initiative, a multicenter population-based observational cohort study of knee OA. The participants were asked to describe where they experienced pain: the lower back, neck, shoulder, wrist, elbow, ankle foot or knee. Levels of pain were measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). This score ranges from 0 to 20, with lower scores indicating less pain and stiffness.
Results published in Arthritis Care & Research suggest that 57.4% of participants experienced pain in their lower back. Participants with lower back pain had a mean WOMAC pain score of 6.5, while those without lower back pain scored 5.2. Researchers also found that low back pain was significantly associated with an increase in painful knee OA, as indicated by the WOMAC knee pain score. A similar pattern emerged for all other pain locations studied.
Models were used to simultaneously analyze all reported pain locations. Lower back pain, foot pain and elbow pain were found to be significantly associated with a higher WOMAC score for knee pain.
“Future studies are needed to determine whether treatment of pain occurring elsewhere in the body will improve therapy outcomes for knee OA.”
Having more than one pain location was found to be indicative of higher knee pain score, regardless of the location of the other pains. Patients who experienced pain in four or five different locations reported even more severe knee pain.
Knee OA is the leading cause of disability in the USA. According to the Centers for Disease Control and Prevention (CDC) nearly 4.3 million adults over the age of 60 years have the disease.
“Our findings show that pain in the low back, foot and elbow may be associated with greater knee pain, confirming that symptomatic knee OA rarely occurs in isolation. Future studies are needed to determine whether treatment of pain occurring elsewhere in the body will improve therapy outcomes for knee OA,” Suri explained.
Source: Suri P, Morgenroth DC, Kwoh CK, Bean JF, Kalichman L, Hunter DJ: Low back pain and other musculoskeletal pain comorbidities in individuals with symptomatic osteoarthritis of the knee: data from the osteoarthritis initiative. Arthritis Care Res. 62(12), 1715–1723 (2010).
A recent study suggests that a single injection of morphine, intended to combat persistent pain in male rats, also reduces the level of testosterone in the brain and plasma.
The study, published in Molecular Pain, set out to investigate previous observations that patients treated with opioids show decreased levels of gonadal hormones. This hormone decrease has been linked to menopausal symptoms in women and andropausal symptoms in men.
“Opioid induced hypogonadism can cause health complications to which patients with pain can be overly susceptible, including chronic fatigue, loss of stamina, emotional and sexual disturbances, as well painful skeletal and muscular complications” commented Marco Pappagallo, Professor and Director of Pain Research and Development, Department of Anesthesiology, Mount Sinai School of Medicine, NY, USA.
In the study, male rats were injected with a 5-mg dose of morphine and the formalin test was used to determine whether this had any effect on persistent pain. Testosterone levels were then measured and were found to be greatly reduced in the brain and plasma of morphine-treated rats. However, variations in hormone levels were not always associated with behavioral changes.
The decrease in testosterone was attributed to an increase in aromatase, an enzyme that breaks down testosterone and is involved in the synthesis of estradiol. Both testosterone and estradiol are important hormones, engaged in cognitive functions and motor control.
“The use of opioids puts a ‘physiological‘ block on the reproductive system and can induce a long lasting absence of these essential hormones from the blood and the brain,” explained lead author Anna Maria Aloisi, University of Siena, Italy. “The normal effect of opioids to restrict reproduction in stressed subjects is multiplied by the higher levels/long duration of opioids in the body.”
The side effects of using opioid drugs to treat chronic pain are a concern for patients and physicians alike. However, the study authors do not advise limiting the use of opioid drugs for the treatment of persistent pain, instead they emphasize that physicians should consider hormone replacement therapy in order to improve the quality of life of opioid users who experience hormonal side effects.
Source: Aloisi AM, Ceccarell I, Fiorenzani P et al.: Aromatase and 5-a reductase gene expression: modulation by pain and morphine treatment in male rats. Mol. Pain 6, 69 (2010).