New research from the University of Warwick’s Department of Psychology (Warwick, UK), suggests that chronic pain sufferers could be kept physically active by improving the quality of their sleep. The authors reported that sleep was a worthy target for treating chronic pain and not only as an answer to pain-related insomnia.
One of the study’s authors study Nicole Tang (Warwick University) commented “Engaging in physical activity is a key treatment process in pain management. Very often, clinicians would prescribe exercise classes, physiotherapy, walking and cycling programs as part of the treatment, but who would like to engage in these activities when they feel like a zombie?”
In the study the authors examined the day-to-day association between night-time sleep and daytime physical activity in chronic pain patients, Tang commented that “Many of the patients struggled to stay physically active after the onset of pain and we found that chronic pain patients spontaneously engaged in more physical activity following a better night of sleep” adding that “The research points to sleep as not only an answer to pain-related insomnia but also as a novel method to keep sufferers physically active, opening a new avenue for improving the quality of life of chronic pain sufferers.”
In the study chronic pain patients wore an accelerometer that measured motor activity to monitor their physical activity round the clock for a week in their usual sleeping and living environment. The patients also they gave ratings of their sleep quality, pain intensity and mood using a mobile electronic diary.
The researchers then used the time-specific data to determine, whether the quality of their sleep had an impact on their levels of physical activity they the following day. Multilevel models for each of the predictors were fit, and the only reliable predictor of physical activity was sleep quality.
The authors reported that a comparison between multilevel models demonstrated that sleep was a better predictor of physical activity than morning ratings of pain intensity or mood.
Discussing the study Tang said that “the prospect of promoting physical activity by regulating sleep may offer a novel solution to an old problem” “The current study identified sleep quality, rather than pain and low mood, as a key driver of physical activity the next day. The finding challenges the conventional target of treatment being primarily focused on changing what patients do during the day. Sleep has a naturally recuperative power that is often overlooked in pain management. A greater treatment emphasis on sleep may help patients improve their daytime functioning and hence their quality of life.”
Source: University of Warwick Press Release – ‘Sleep may stop chronic pain sufferers from becoming ‘zombies’’: www2.warwick.ac.uk/newsandevents/pressreleases/sleep_may_stop/
A recent study from researchers at Carolinas Pain Institute and Center for Clinical Research (NC, USA) suggests that patients who benefited from intradiscal biacuplasty (IDB) to treat discogenic low-back pain maintained initial gains in pain relief and physical function at a 1-year follow-up. Additionally, the paper appears to demonstrate that patients who were in the sham treatment group and were later offered IDB achieved the same positive results as patients in the original treatment arm.
With the need for less invasive treatment options to treat discogenic low-back pain, interest in the use of IDB is growing. The treatment involves placing two cooled radiofrequency (RF) electrodes in affected discs to ablate the nerve fibers of the intervertebral disc cover, thus interrupting the generation of pain sensations.
Discussing the study Leonardo Kapural (Carolinas Pain Institute and Center for Clinical Research) highlighted the importance of candidate selection: “This minimally invasive procedure should be limited to younger patients with discogenic pain arising only from 1 or 2 lumbar discs and without other sources of lower back pain.”
The study is a follow-up to a 6-month, double-blind, sham, randomized study. After unblinding, the investigators continued to follow 22 out of 27 subjects in the original active treatment group for 12 months. Patients reported outcomes on physical function, pain and disability via the SF-36 health survey, the 11-point pain numerical rating scale (NRS) and the Oswestry low-back pain disability questionnaire.
Clinically significant improvements reported at 6 months in the original treatment arm were maintained at 9 and 12 months for physical function.
Additionally, crossover patients who had been randomized to sham therapy during the initial study reported improvements after IDB that did not differ statistically from those of patients originally randomized to IDB treatment.
Discogenic pain is the most common cause of chronic low-back pain and although the findings appear exciting Kapural emphasizes that the majority of sufferers have multilevel disease and would not be candidates for IDB. Adding that current surgical treatment options are limited to fusion and disc arthroplasty and have been suggested to yield very low success rates.
Source: Newswise Press Release – ‘Study shows long-sasting improvements for discogenic low-back pain treated with minimally invasive intradiscal biacuplasty’: www.newswise.com/articles/study-shows-long-lasting-improvements-for-discogenic-low-back-pain-treated-with-minimally-invasive-intradiscal-biacuplasty
Researchers from the University of Adelaide (Adelaide, Australia) are reporting that new insights into how the human brain responds to chronic pain could eventually lead to improved treatments for patients.
One of the researchers involved in the study, Ann-Maree Vallence (University of Adelaide) commented “Neuroplasticity underlies our learning and memory, making it vital during early childhood development and important for continuous learning throughout life. The mechanisms responsible for the development of chronic pain are poorly understood. While most research focuses on changes in the spinal cord, this research investigates the role of brain plasticity in the development of chronic pain.”
The study included patients with chronic tension-type headache (CTTH), a common chronic pain disorder, characterized by a dull, constant feeling of pressure or tightening usually affecting both sides of the head, occurring for 15 days or more per month. Other symptoms include poor sleep, irritability, disturbed memory and concentration, and depression and anxiety.
Discussing the condition Vallence commented “People living with chronic headache and other forms of chronic pain may experience reduced quality of life, as the pain often prevents them from working, amongst other things. It is therefore imperative that we understand the causes of chronic pain, not just attempt to treat the symptoms with medication.”
In the study, subjects undertook a motor training task and their change in performance on the task was tracked. Additionally, a non-invasive brain stimulation technique was used to obtain a measure of the participants’ neuroplasticity.
Vallence noted that “Typically, when individuals undertake a motor training task such as this, their performance improves over time and this is linked with a neuroplastic change in the brain. The people with no history of chronic pain got better at the task with training, and we observed an associated neuroplastic change in their brains. However, our chronic headache patients did not get better at the task and there were no associated changes in the brain, suggesting impaired neuroplasticity.” Vallence added that “These results provide a novel and important insight into the cause of chronic pain, and could eventually help in the development of a more targeted treatment for CTTH and other chronic pain conditions.”
Source: University of Adelaide Press Release – ‘Chronic pain research delves into the brain’: www.adelaide.edu.au/news/news69222.html
Results reported in a scientific poster today at the 30th Annual Meeting of the American Academy of Pain Medicine suggest that scientists can predict which osteoarthritis (OA) patients with neuropathic pain symptoms will respond to treatment with NSAIDs by assessing the nervous system’s own capacity to regulate pain. In the study patients whose tests had indicated superior conditioned pain modulation (CPM) had less pain and fewer neuropathic symptoms at study’s end.
One of the investigators AD Wasan (University of Pittsburgh, PA, USA) noted “Clinically, these results indicate that neuropathic symptoms are very common in knee OA and that neuropathic processes – such as changes in conditioned modulation – predict who will respond to a common treatment for knee OA. Patients with neuropathic pain symptoms in OA respond equally as well to topical NSAIDS as those who do not have neuropathic pain symptoms.”
The results come from a 5-week effectiveness study of diclofenac topical gel in 44 patients with knee OA. Patients were extensively tested as to genetically and environmentally influenced physical characteristics. The authors also used the Neuropathic Pain Questionnaire, the Knee Injury and Osteoarthritis Outcome Score, an exercise performance task and quantitative sensory testing (QST).
Of the 38 subjects who completed the study, 40% had significant neuropathic symptoms, that included burning or shooting sensations and sensitivity to touch. Pain sensitivity at baseline, as measured by QST, had modest correlation to symptoms.
After 4 weeks of treatment with diclofenac gel, there was 30% improvement in pain on average and significant response for neuropathic symptoms and improved function.
Using CPM, an index of endogenous pain-inhibitory capacity, calculated from QST measurements, investigators correctly predicted changes in pain intensity and in neuropathic symptoms. Subjects with higher CPM at baseline, representing better functioning endogenous pain-inhibitory systems, reported lower pain intensity and neuropathic pain symptoms at the study’s end.
The variability of the pain experience along with observations that pain can change in the presence of other factors, including past memories, stress, anxiety, distraction or attention, further suggests the presence of endogenous pain modulatory systems.
Source: Newswise Press Release – ‘Higher functioning endogenous opioid system predicts better treatment response for neuropathic pain treated with topical NSAIDs: study: www.newswise.com/articles/higher-functioning-endogenous-opioid-system-predicts-better-treatment-response-for-neuropathic-pain-treated-with-topical-nsaids-study
New research presented at the 30th Annual Meeting of the American Academy of Pain Medicine suggests that postsurgical pain scores are highly correlated with reports of overall patient satisfaction during hospital stays.
The goal of the research, led by Dermot Maher (Cedars Sinai Medical Center, CA, USA), was to clarify the relationship between pain control after surgery and the answers provided by patients on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS is the first national, standardized, publicly reported survey of patients’ perspectives on the care they receive in the hospital which is filled out at the time of discharge and is a factor in value-based incentive payments following the implementation of the Affordable Care Act of 2010.
Discussing the study Maher noted “This study illustrates the crucial role that pain management in the acute postoperative setting can have, not only on a patient’s perception of pain management, but also on the global perception of their hospitalization.”
In the study the investigators examined HCAHPS responses by 2933 surgical patients who were hospitalized at a single trauma center between March 2012 and February 2013. Two questions assessing satisfaction with in-hospital pain management and two addressing general satisfaction demonstrated a statistically robust relationship when retrospectively compared with patient pain scores as assessed via the postanesthesia care unit visual analog scale.
Maher highlighted the importance of these findings saying “Patients consider a number of factors when evaluating physicians and hospitals. One of the most influential factors is a patient’s perception of pain. The universal unpleasantness and complicated nature of pain, especially in the postoperative setting, has the potential to negatively impact overall satisfaction if not optimally managed.”
Further analyses of the data demonstrated that patients who had surgery related to spine, non-spine orthopedics, and obstetrics and gynecology demonstrated significantly larger correlations of postanesthesia care unit pain scores with HCAHPS responses than patients who had other types of surgeries. Maher points out that the stronger association between HCAHPS scores and postoperative pain in certain populations calls into question the appropriateness of universal application of patient satisfaction surveys, or at least the pain component, as a means of reimbursement.
In addition to highlighting the need for better postoperative pain control for patients, Maher noted that the study indicates additional value in identifying anesthetic techniques that might improve patient overall satisfaction.
Source: American Academy of Pain Medicine Press Release – ‘Postsurgical pain control linked to patient satisfaction with hospital experience’: www.painmed.org/2014press/files/postsurgical-pain-control-linked-to-patient-satisfaction-with-hospital-experience.pdf
A recent study suggests that two hormones credited with reducing pain and need for opioid analgesics when released during pregnancy and childbirth work similarly when administered simultaneously to patients with intractable pain.
In the study following doses of oxytocin (OT) and human chorionic gonadotropin (HCG), seven out of nine patients reported a reduction in opioid use and baseline pain. Additionally, the patients reported less intense pain flares, and longer periods between flares.
One of the authors of the study Forest Tennant (Veract Intractable Pain Clinic, CA, USA) commented that side effects were remarkably few, probably due to the fact that the hormones are natural, bio-identical compounds. Tennant added that “The benefit that these patients mostly talk about is somewhat subjective but relates to what patients routinely call a ‘feeling of well-being,’ ‘more alive,’ or [increasing] ‘will to live. They also believe the combination is one they want to continue.”
OT exerts powerful action in the neuroanatomy of intimacy and also acts as a neurotransmitter in the brain. HCG supports the development of the fetus during pregnancy among other roles. During and after childbirth the levels of both hormones surge, and pregnant women frequently exhibit reduced pain and need for opioids. Previously, Tennant has conducted small open-label studies that confirmed a similar effect for both hormones when administered separately in patients who suffer from intractable pain. However, until now no one had tested the effect of administering both hormones simultaneously.
The study included nine patients with intractable pain who were being maintained on one or more long- and short-acting opioids. Daily dosages were administered beneath the tongue of HCG ranging from 250 to 500 units and OT in 10 units taken 2 –4 times. Patients were evaluated for pain relief, side effects, energy, mental function and opioid dose reduction at 2 to 3 months.
One patient stopped the regimen entirely, saying it had no effect and another stopped taking OT because it made her weepy and despondent but continued taking HCG.
All other patients reported a 30–40% reduction in opioid use, reduction in baseline pain, flare intensity, or increase in time between flares. Reports of energy, improved mental functions, mood and libido were variable.
Tennant commented that it is premature to justify this type of hormonal therapy in anyone but patients who are nonresponsive to standard treatments, these preliminary results are worth pursuing as an alternative to more symptomatic conventional treatments for intractable pain. However, future open-label trials by multiple observers are necessary to assess the clinical relevance of the results. Tennant says he expects biomarkers of neuroinflammation and glial cell metabolic disturbance to be useful for monitoring treatment success and, to a great extent, influencing treatment selection.
Source: Newswise Press Release – ‘Combined use of oxytocin and human chorionic gonadotropin in intractable pain patients’: www.newswise.com/articles/combined-use-of-oxytocin-and-human-chorionic-gonadotropin-in-intractable-pain-patients
A recent study conducted by researchers at the University of Manchester (Manchester, UK) suggests that the abnormalities in the way the brain experiences pain may be to blame for the chronic pain suffered by osteoarthritis patients, highlighting the need for new therapies to target brain mechanisms to enable the brain to cope more effectively with chronic pain, including mindfulness-based talking therapies.
One of the study’s authors, Anthony Jones (University of Manchester), commented “The extent of pain experienced by sufferers of arthritis has always been thought to result from the direct consequences of joint destruction. However the extent of pain is often poorly related to the amount of damage and can spread to nearby regions of the body where there is no evidence of arthritic disease. We wanted to look at what might be causing this. Currently it is not understood why patients with arthritis have such variability in how much pain they experience but, in spite of this, we continue to spend large sums of money using potentially damaging anti-inflammatory drugs.”
Researchers thought that the spreading and intensification of pain in arthritis may be similar to that experienced by sufferers of fibromyalgia. Earlier research suggested that patients with fibromyalgia have abnormalities in the way in which the brain deals with pain prompting the team to look at the overlaps in how pain is processed in the brain in osteoarthritis.
The team measured brain waves in response to short painful laser pulses to the skin in patients with osteoarthritic or fibromyalgic pain and those with no pain. They reported that while anticipating the painful pulse a brain area called the insula cortex increased its activity and this predicted the extent and intensity of the patients’ own chronic pain.
Another of the study’s authors, Christopher Brown (University of Manchester) noted “Increased activity in this brain area has been linked to a number of phenomena, including body perception and emotional processing, which might explain the greater pain perception in some patients. Interestingly, responses during pain anticipation were reduced in an area at the front of the brain called the dorsolateral prefrontal cortex. These reduced responses corresponded to less ability to develop positive ways of coping with the pain in both groups of patients. We think that boosting activity either directly or indirectly in this area of the brain is likely to result in better coping and better control of pain responses in other areas of the brain.”
Another author, Wael El-Deredy (University of Manchester), added “More research is needed but this suggests we should be putting more resources into a common approach to developing new therapies that target these potential brain mechanisms. Our previous work has shown that brain responses to pain expectation can be altered by relatively short and inexpensive mindfulness-based talking therapies in patients with different types of chronic pain. Our current findings therefore provide both a new target for development of new therapies and some optimism for simple interventions to improve the brain’s control of chronic suffering endured by many patients with chronic pain conditions.”
Source: University of Manchester Press Release – ‘New research points to talking-therapy treatments to manage osteoarthritis pain’: www.manchester.ac.uk/aboutus/news/display/?id=11695
– All stories written by Dominic Chamberlain