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Anesthesiology, Pain, Research, Stanford News

Stanford researchers address the complexities of chronic pain

Stanford researchers address the complexities of chronic pain

If you’re in a reading kind of mood today, I highly recommend feeding it with a recent STANFORD Magazine feature on chronic pain and some of the research Stanford scientists are conducting to address it.

Chronic pain is usually defined as lasting longer than six months, the article notes, and may be present in 30 percent of adults in the United States. Owing to causes such as complex regional pain syndrome, arthritis, fibromyalgia, migraines or persistent lower back pain, many people turn to opioid medications, which can be addictive. The article notes some stunning statistics, such as this one – “More Americans are now dying as a result of prescription opioid overdose than from cocaine or heroin overdose.”

And this one: “In addition to the cost in human suffering, chronic pain costs the United States more than half a trillion dollars annually in direct medical expenses and lost productivity, according to a 2011 Institute of Medicine report (chaired by former School of Medicine dean Philip Pizzo, MD). This is more than the cost of heart disease and cancer combined.”

The article details research at Stanford working to understand the location and physiology of certain types of chronic pain, as well as to help patients overcome the lingering negative emotional effects it may produce.

Sean Mackey, MD, PhD, chief of the division of pain management at Stanford and a professor of anesthesia, said in the article, “When pain becomes persistent, it can become a disease in its own right.”

Previously: Retraining the brain to stop the painExploring the mystery of painMore progress in the quest for a “painometer and Ask Stanford Med: Neuroscientist responds to questions on pain and love’s analgesic effects

Aging, Health and Fitness, Orthopedics, Pain, Research

Exercise programs shown to decrease pain, improve health in group of older adults

Exercise programs shown to decrease pain, improve health in group of older adults

LASHER ILICEvery time I read about research on the benefits of exercise, I become eager to go outside and run. (Or, realistically, take a pleasant walk.) But before I do that today, I wanted to share a study showing that participating in an exercise program led to a decrease in pain from arthritis and other musculoskeletal conditions, as well as an improvement in mobility and overall health, among a group of older adults.

The research, which was presented today at the American Public Health Association Annual Meeting in Boston, involved 119 adults of Asian descent – most of them female and age 65 or older – living in New York City. Participants took part in multiple eight-week yoga exercise classes and sessions of the Arthritis Foundation Exercise Program between 2011 and 2013. The community-based classes were conducted by the Hospital for Special Surgery‘s Asian Community Bone Health Initiative using bilingual instructors at senior centers in the Chinatown, Flushing and Queens neighborhoods.

A release explained why the researchers focused on Asian adults:

The Asian older adult population in New York City grew by 64 percent from 2000 to 2010, and one in four seniors lived in poverty in 2010. “This population is at risk for osteoarthritis and osteoporosis,” said Laura Robbins, DSW, senior vice president of Education and Academic Affairs at HSS. “They are more than twice as likely to have no health insurance coverage compared to other major race and ethnic groups. Cultural and linguistic barriers limit access to healthcare services.”

And as for results:

In the survey, many participants reported that their pain intensity dropped and interfered less with their quality of life. The following statistically significant results are noteworthy:

  • 48% fewer participants had pain on a daily basis after completing the program
  • 69% more participants could climb several flights of stairs after the program
  • 83% more participants could bend, kneel, or stoop
  • 50% more participants could lift/carry groceries
  • 39% of participants felt the program reduced their fatigue
  • 30% participants felt that the program reduced their stiffness

Previously: Exercise is valuable in preventing sedentary deathModerate physical activity not a risk factor for knee osteoarthritis, study showsResearchers look at brain activity to study falling and Help from a virtual friend goes a long way in boosting older adults’ physical activity
Photo by ASSOCIATED PRESS

Chronic Disease, Pain

Letting go of control during chronic illness or pain

A friend who recently had inpatient surgery on her sinuses texted that she was on a 10-day yoga time-out. And no pranayama, either, of course, because the practice requires deep, deliberate breathing. This is a big deal for someone who’s yoga-obsessed! She put her furlough in perspective: “I can barely stand.”

When you’re feeling lousy, sometimes it’s extra hard to forgo your normal sources of pleasure and calm. In a recent post on KevinMD.com, patient Toni Bernhard, JD, writes about lessons she’s learned from her body and provides guidance for others dealing with chronic pain or illness.

Bernhard the patient has replaced her healthy law-professor self’s to-do list with a “not-to-do list” that includes willing her body to accomplish things it’s warning her to skip. Instead, she recommends to other patients, be kind to your present self and honor the body you have, exercise caution when considering a risky new treatment, and let go of what won’t serve you – such as a frozen image of your pre-illness self. (Sounds a lot like yoga, even on a time-out.)

Previously: Fibromyalgia – living with a controversial chronic disease“Live Because:” Living a fuller life with chronic illnessWhen you say nothing at all: Living with an invisible illness and Study shows poor sleep may increase risk of fibromyalgia among women
Via @dennisjboyle

In the News, Pain, Research, Science

Along came a spider: Spider venom could be the basis for a non-addictive pain blocker

Along came a spider: Spider venom could be the basis for a non-addictive pain blocker

spiderI like reading and writing so all of the spiders in my house are exceptionally well-read. I think. They’re all buried under a pile of books so it’s hard to tell.

But now I feel a sharp twinge of remorse for flattening so many of my eight-legged housemates after reading this story on the Eek Squad blog. Spider venom, as the blog explains, may provide humans and their companion animals with a non-addicitve way to block pain.

From the blog:

Pain usually means something is wrong, but for people suffering from chronic pain — like from arthritis, cancer or other illnesses — powerful pain blockers are the only thing that help.

While most pain relief drugs take a shotgun approach, venom-based molecules can zero in on a single channel or enzyme. Though this evolved for the more nefarious purpose of subduing and paralyzing prey, it could also stop pain in its tracks. Researchers are still trying to figure out how to tweak spider venoms to avoid affecting heart function and other muscles, however.

The benefits of spider venom extend beyond pain relief in people. Dr Maggie Hardy at the University of Queensland in Australia is working on spider venom-based treatments for your pets, too.

Researchers, such as Greg Holland, PhD, of Arizona State University, are also making headway by studying the molecular structure of spider venom. “Structure directly relates to how something functions, so in order to understand its function, you have to solve its structure,” Holland explained in this Inside Science TV story.

At this point, spider venom-based pain blockers are not yet available for humans or their pets.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Another big step toward building a better aspirin tabletRetraining the brain to stop the painA physician’s personal odyssey with chronic painFibromyalgia – living with a controversial chronic diseaseVexing venom delivered on the web, and Exploring the mystery of pain
Photo by cheetah 100

Immunology, Neuroscience, Pain, Research, Stanford News, Stroke

Another big step toward building a better aspirin tablet

Another big step toward building a better aspirin tablet

big aspirinNeuroinflammation – inflammation of the brain and spinal cord – is a major driver in a broad spectrum of neurological disorders, from acute syndromes like stroke and head injury to chronic neurodegenerative disorders such as Alzheimer’s and Parkinson’s diseases.

Non-steroidal anti-inflammatory drugs (NSAIDs) are a mainstay of drug therapy against inflammatory conditions from arthritis to headaches to back pain. And there are indications that daily use of some NSAIDs (for instance aspirin) may fend off conditions of neuroinflammatory origin such as Alzheimer’s and Parkinson’s.

There’s also good evidence that much of neuroinflammation’s sting can be traced to barbs called microglia - a collective term denoting the brain’s very own set of immune cells. As first-rate scientists including Ben Barres, MD, PhD, and others have written, malfunctioning microglia may underlie much of what goes wrong in the arc of neurodeneration.

A new study by Stanford neuroscientist Kati Andreasson, MD, suggests that putting the chill on neuroinflammation by shutting down a particular protein on the surface of microglial cells may be beneficial.

In a 2011 release describing earlier work along these lines by Andreasson, I wrote:

NSAIDs block both COX-2 and COX-1, two very similar versions of cyclo-oxygenase, an enzyme that catalyzes a key chemical reaction in the production of five related hormone-like messenger molecules called prostaglandins… Prostaglandins travel from one cell to another, landing on… dedicated receptor molecules sitting on cells’ surfaces and stimulating various activities inside those cells. Each type of prostaglandin can trigger distinct effects. One prostaglandin in particular, PGE2, is known to be associated with pain and inflammation. PGE2 has four separate counterpart receptors, designated EP1 through EP4, each of which sets in motion a different set of activities inside cells on binding to PGE2.

In the new study, which appears in the Journal of Neuroscience, Andreasson and her colleagues (including fellow Stanford neuroscientist Marion Buckwalter, MD, PhD,) specifically blocked PGE2′s function in mice’s microglia. Doing this reduced brain inflammation in the presence of toxins that are known to be highly neuroinflammatory – including one called MPTP, a substance that has caused Parkinson’s disease among young drug users. Importantly, nerve cells located in the substantia nigra, a tract whose demise is a central feature of Parkinson’s disease, suffered much less damage in the presence of MPTP among mice whose microglia were missing PGE2.

“NSAIDs have a number of adverse effects, because blocking the COX enzymes blocks not only toxic prostaglandin actions but beneficial ones as well,” Andreasson told me. “If we can put our finger on prostaglandins’ toxic downstream effects, such as the microglial effect examined in this paper, we should be able to generate safer, stronger therapies in neurological disease, and other diseases as well.”

Previously: Untangling the inflammation/Alzheimer’s connection, When brain’s trash collectors fall down on the job, neurodegeneration risk picks up, Malfunctioning microglia – brain cells that aren’t nerve cells – may contribute big time to ALS and other neurological disorders and Neuroinflammation, microglia and brain health in the balance
Photo by wilbanks

Neuroscience, Pain, Pediatrics, Stanford News

Retraining the brain to stop the pain

Retraining the brain to stop the pain

“They’re probably just growing pains,” my mom would say in an upbeat, informative tone of voice, as though that insight would serve as a dab of verbal salve to ease the ache of the weird “pains without an obvious cause” that I occasionally experienced while growing up. “Give them time, they’ll go away.”

And she was always right. Those weird, seemingly sourceless pains – often in my legs – always faded. Lots of kids have pains like that, but sometimes the pain doesn’t go away – sometimes it just keeps getting worse. In that vein, there’s a story out of Lucile Packard Children’s Hospital about a 13-year-old girl who had heel pain, without any obvious cause, that got so severe she couldn’t even dip her heel in water.

She ended up being treated by Elliot Krane, MD, director of the Pediatric Pain Management Program at Packard Children’s. How he and an occupational therapist treated her by “retraining” her brain and some misfiring nerves is a fascinating read – all about coping with the mysterious realm of complex regional pain syndrome.

And for more, Krane discusses the complexities associated with treating CRPS in this TED talk and shares information on how nerves work in this TED Ed talk.

Previously: Exploring the mystery of pain, Helping kids manage chronic painMore progress in the quest for a “painometer”, A call to fight chronic-pain epidemic, Relieving Pain in America: A new report from the Institute of Medicine and Elliot Krane discusses the mystery of chronic pain

Medicine and Society, Pain, Patient Care, Public Health, Stanford News

A physician’s personal odyssey with chronic pain

A physician’s personal odyssey with chronic pain

Philip Pizzo, MD, former dean of Stanford’s medical school was preparing to head to Washington, D.C. to meet with top federal health officials when he leaned down in his office and felt the sharp sting of pain. It would be the beginning of a long odyssey into the world of chronic pain – the very subject he had planned to go to Washington to discuss.

The chair of an Institute of Medicine panel on pain, Pizzo and his colleagues had issued a report in late 2011 calling for a transformation in approaches to pain, which affects more than 100 million Americans. Suddenly he would find himself among the afflicted as he sought the opinions of multiple physicians and underwent four MRI’s, turning increasingly despondent as the months dragged on with no diagnosis.

My hope is that by sharing my personal story, it will generalize the discussion and create more dialogue about the realities that 100 million people face…

“I could easily still have been one of the many tens of thousands or millions facing chronic pain without explanation, because I had been through all the standard testing,” he said in an interview. “I had four MRI scans and none showed the lesion that ultimately contributed to my finding. The reality was because I am a physician and I kept saying, ‘Gee, there is something wrong that hasn’t been found,’ people were responsive.”

In writing about the experience in today’s New England Journal of Medicine (subscription required), Pizzo says the specialists he encountered were often circumscribed in seeking answers. He told me, “While it’s not an indictment of the medical system, it’s a reality that many have faced – physicians and providers are rushed, specialization is so significant that many people think within narrow boundaries. They don’t leap beyond their own expertise. That is another thing we have to challenge ourselves with - to think beyond the usual.”

As time wore on, he said, at least one physician would suggest that his condition was largely psychological - essentially “all in your head.”

“What I experienced is what many do when you get beyond the point when conventional tests aren’t revelatory. The medical community gets frustrated – gee we can’t find anything – and begin to think maybe there are other things happening, some suggestion perhaps that it was distress or depression… It’s easy for physicians to say you are depressed and that’s why you have pain. But it’s important to recognize that patients may be depressed because they have pain.”

A marathon runner with boundless energy and a perennially upbeat attitude, Pizzo indeed had become clinically depressed as a result of his disabling condition. But once the underlying cause of the chronic pain was diagnosed and treated – albeit with a major surgical procedure – that depression immediately lifted, along with the pain. Ultimately, it was an unusual test - an imaging study that tracked the path of the sciatic nerve - that unearthed the source of his distress, a congenital condition involving compression of the nerve.

After the surgery, Pizzo learned another valuable lesson for physicians - that not all patients respond well to opioids, typically the drugs of choice for control of severe pain. He proved highly sensitive to the medications and landed in intensive care.

Today, Pizzo is back to running and working full-time in his office on the medical school campus. In writing his personal story, he says he hopes to draw more physician attention to the overwhelming problem of chronic pain in the United States.

“My hope is that by doing this, it will generalize the discussion and create more dialogue about the realities that 100 million people face, many of whom don’t have the opportunity to have their voices expressed.”

Previously: The high cost of pain: Medical school dean testifies on problem to U.S. SenateA call to fight chronic-pain epidemic, No pain, no gain. Not!, Relieving Pain in America: A new report from the Institute of Medicine and Researching ways to “heal the hurt”

Cancer, Health Disparities, Pain, Research

Identifying disparities in palliative care among cancer and non-cancer patients

Earlier this month, the New York Times reported on financial and ethical considerations for entering a hospital’s palliative care unit, which serves people with chronic illnesses near the end of life who need comfort more than intensive care but are not yet ready for hospice.

Now a study conducted in the U.K. has found that only 20 percent of non-cancer patients there (those with advanced stages of heart, lung, liver or kidney conditions, or dementia) requested or were properly identified as candidates to receive palliative care. That’s compared with 75 percent of cancer patients.

The study (subscription required), published in the European Journal of Palliative Care, examined 684 patients under general practitioner care in Scotland. Researchers found that most of the non-cancer patients began receiving palliative care too late to fully benefit from it – usually eight weeks before dying – and that non-cancer conditions were more difficult to prescribe palliative care for during a less-clear decline.

In a release, Scott Murray, MD, who leads the Primary Palliative Care Research Group at the University of Edinburgh, commented:

Patients with cancer are generally well served by palliative care services, while people with other conditions often miss out on this opportunity for more psychological, emotional, spiritual and practical support. Better and earlier identification of all patients who may benefit from these services is vital so that they can receive the care they need, and not slip through the net.

hospiceAfter hearing about the study, I asked palliative care expert VJ Periyakoil, MD, director of the Stanford Palliative Care Education & Training Program and the Stanford Hospice & Palliative Medicine Fellowship Program, to comment on the findings. She replied:

The study results aren’t surprising. Clinicians refer their seriously ill patients to hospice care based on their functional status, which is defined as an individual’s ability to perform normal daily activities required to meet basic needs, fulfill usual roles. As you can see in the image here, most cancer patients have a clear and steady decline in functional status when they get closer to death. Thus when people with advanced cancer spend most of the day in bed and are not able to care for themselves, it’s pretty clear that they’re nearing death and need to be referred to hospice. However, in non-cancer illnesses like end stage heart disease, end stage lung disease, the patient’s functional status undulates (i.e. when they have an infection their functional status becomes temporarily low only to rebound when they recover from the infection). Thus, it’s hard to predict when the patients are in the last six months of their life, and so they’re often referred too late to hospice care. We can overcome these challenges easily by providing concurrent palliative care along with disease directed care for all seriously ill patients.

Previously: Examining end-of-life practices and Katy Butler’s “Knocking on Heaven’s Door”How a Stanford physician became a leading advocate for palliative careOn a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

Chronic Disease, Pain

Fibromyalgia – living with a controversial chronic disease

Fibromyalgia – living with a controversial chronic disease

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; the latest comes from health writer Marijke Vroomen.

I can’t imagine anyone relishing the idea of being tired, in pain, or suffering from “brain fog” for one day, let alone for months or years. If you have fibromyalgia, this is what you experience on a regular basis. Yet there are people who believe that fibromyalgia doesn’t exist – that it’s a made-up disease with the purpose of appeasing patients, giving their complaints a name.

Incidences of muscle pains characteristic of modern-day fibromyalgia have been documented for centuries, but only in the 1970s did the disease begin receiving serious attention as physicians began to better identify trigger points, inflammation, and fibromyalgia-associated issues such as sleep disorders and irritable bowel. And only in 1987 did the American Medical Association recognize fibromyalgia as “an emerging condition.” But saying it’s a disease and convincing non-believers are two different things.

I’ve been asked what it’s like to have fibromyalgia and, just as it’s difficult to diagnose, it’s difficult to explain. Although I was only diagnosed a few years ago, I can trace the symptoms to my teens. I often experienced unexplained bouts of exhaustion and pain. I never slept well. I had other fibromyalgia-related physical issues, but no one could figure out what was wrong. After a while, I began to believe that it was all in my head. I knew I felt the pain, but there was no explanation. I knew I was exhausted, but everyone is tired – why would I be any different? The other symptoms? I was overplaying them, complaining too much, imagining them, looking for attention, wasn’t I?

My family and close friends were (and still are) wonderful. They never made me believe that I shouldn’t be feeling what I was experiencing. They tolerated my quirks, such as the hypersensitivity that results in a very strong startle reflex and not being able to stand the feel of certain things against my skin. (It wouldn’t surprise me if the princess in fairy tale The Princess and the Pea had fibromyalgia!) My husband, my children, my friends, all helped me when the pain was bad and the exhaustion overwhelming. But feeling so different and not knowing why take a toll on a person.

I did what many with fibromyalgia do. I withdrew into myself. By withdrawing, you minimize your chances of being criticized or attacked by those who don’t understand your “nonexistent” illness. But at the same time, because you are internalizing everything, your symptoms become worse. Your mind plays more games. And the cycle continues.

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Cancer, Complementary Medicine, Health and Fitness, Pain

A cancer survivor’s yoga journey

A cancer survivor's yoga journey

yoga4

Yoga is my favorite thing. As a former dancer, I love the efficiency of strengthening and stretching my entire body in one practice, and the focused flow found by paying attention to the activity of body, mind, and surroundings. This Well blog essay on a patient’s use of yoga after a series of aggressive and depleting cancer treatments beautifully describes what listening to our bodies can reveal. From the piece:

As we became warriors, children, cats, cows and pigeons, I realized that concentrating on position and breath takes even the most cerebral of us out of our nattering, hectoring brains, reminding us that we have feet, ankles, knees, a spinal column, arms, shoulders, neck, mouth, all of which can stretch and relax, stretch and relax to release tension.

Body awareness — the mind aware of the body, the body of the mind — provides physical but also psychological therapy.

A four-year-long zombie stoicism had been broken. With relief, I realized that yoga was teaching me to be patient with my frailties.

Previously: The promise of yoga-based treatments to help veterans with PTSDNIH hosts Twitter chat on using mind and body practices for managing holiday stress and anxietyStudy offers insights into how yoga eases stress and Study shows mindfulness may reduce cancer patients’ anxiety and depression
Photo by Bliss Flow Yoga

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