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Pain

Autoimmune Disease, Pain, Research

Rheumatoid arthritis patients fare better than 20 years ago, study reports

Some encouraging news about rheumatoid arthritis (RA), a systemic autoimmune disease that causes painful, swollen joints: A new study out of The Netherlands has shown that people recently diagnosed with the disorder have an easier time with daily functioning than patients who were diagnosed 20 years ago, as measured by levels of depressed mood, anxiety and physical disability associated with the condition.

Earlier diagnosis, prescription of physical exercise, and more aggressive drug interventions are responsible for patient improvements, according to the study, which was published in the journal Arthritis Care & Research. From a press release:

For the present study, researchers recruited 1151 with newly diagnosed RA between 1990 and 2011. Participants were 17 to 86 years of age with 68% being female. Each participant was assessed at the time of diagnosis and monitored for the following three to five years.

Findings indicate that after the first four years of treatment 20 years ago, 23% of RA patients reported anxiety, 25% depressed mood, and 53% had physical disability compared to 12%, 14% and 31%, respectively, today. The decrease in physical disability remained significant even after adjusting for reduced disease activity. Results suggest that the downward trend in physical disability, anxiety, and depressed mood may be due in part to reduced disease activity.

“Our study determined that currently, 1 out of 4 newly diagnosed RA patients are disabled after the first four years of treatment; while 20 years ago, that figure was higher at 2 out of 4 patients,” concludes [Cécile L. Overman, a Ph.D. Candidate with the Department of Clinical and Health Psychology, Utrecht University]. “Today, RA patients have a better opportunity of living a valued life than patients diagnosed with this autoimmune disease two decades ago.”

Previously: Important metabolic defect identified in immune cells of rheumatoid arthritis patientsMany lupus patients on Medicaid fail to take medication as prescribed, study shows and Collaboration between Stanford and UCSF aims to advance arthritis research

Ask Stanford Med, Complementary Medicine, Nutrition, Pain

Ask Stanford Med: Pain expert responds to questions on integrative medicine

Ask Stanford Med: Pain expert responds to questions on integrative medicine

rolfing2Sometimes the best medicine is staying healthy. As more Americans look for ways to improve their health, prevent disease and manage pain, the subject of complementary practices may enter more conversations between patients and physicians. So for this installment of Ask Stanford Med, we asked Emily Ratner, MD, clinical professor of anesthesiology, perioperative and pain medicine and co-director of medical acupuncture and the resident wellness program at Stanford, to respond to questions on integrative medicine. Her answers appear below.

As a reminder, these answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

Mary says: Please speak about the efficacy of integrative medicine to alleviate multi-point pain from a variety of causes (ITP, OA, aging). A relative has doctor fatigue as well, and is not interested in anything else.

Integrative Medicine (IM) may be defined as the combination of conventional and nonconventional modalities chosen by a patient and physician in a patient-centered decision-making process in order to achieve the best outcome for an individual. Patients often seek nonconventional modalities when conventional medicine techniques are unable to achieve a particular goal, often pain relief or pain management. As a general rule, multi- and inter-disciplinary measures are often most helpful in relieving suffering from pain. These may include five general categories of nonconventional modalities, although there is overlap amongst the different types:

  • Mind-body medicine: meditation, hypnosis, biofeedback, guided imagery, yoga
  • Biologically based practices: uses substances found in nature – herbs, foods, vitamins, supplements
  • Manipulative/Body-based practices – massage, chiropractic/osteopathic manipulation
  • Whole medical systems: Traditional Chinese Medicine (includes acupuncture), Ayurveda, naturopathy
  • Energy Medicine – Reiki, Healing/Therapeutic touch, Qi Gong, acupuncture, yoga

Depending on patient preference, available resources in the community and other factors, a decision is made where to begin. I often recommend acupuncture as a place to start, closely followed by a mind-body medicine technique, as my experience is that stress plays a large role in either pain or the perception of pain. However, it largely depends on the individual’s needs and preferences.

Scope Editor asks: A recent study of herbal products found that most of those examined contained contaminants, substitutions and unlisted fillers among their ingredients. What are the implications of these findings, and how can consumers protect themselves when buying supplements?

This is a significant issue that highlights the need for increased supplement regulation, although the study to which you refer has been criticized for some of its conclusions. While FDA regulations for supplements are a bit stricter than for foods, the regulations are far less comprehensive than those for pharmaceutical agents.

That being said, product contamination with heavy metals, undisclosed pharmaceutical agents (especially in products from outside the U.S.), and inaccurate product ingredient amounts plague this field.

Until improved regulatory procedures are instituted, I suggest looking at a reputable database that independently tests these products, such as ConsumerLab.com. This and other independent organizations add their seal of approval to product labels that have tested either the products or the manufacturing practice involved in production of the substance. Look for the Consumer Lab seal or other seals: cGMP (current Good Manufacturing Practice), USP (United States Pharmacopeia), or NSF (another independent lab).

Some experts note that specific stores have strict quality control for their products – like Sam’s Club, Costco, Whole Foods – but I typically look up each individual product on a database (I use consumerlab.com) prior to recommending it.

Another option is to consult with a trained Integrative Medicine practitioner who has access to these databases and is knowledgeable about these products.

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Image of the Week, Pain

Image of the Week: The agony of pain

Image of the Week: The agony of pain

Pain Image

As my colleague wrote about last week, the current issue of Stanford magazine includes a feature, “Make It Stop,” on the pain research happening here. The image above - in my mind, the perfect representation of intense, all-encompassing pain – accompanies the article and makes Kristin Sainani’s piece that much more compelling.

Previously: Stanford researchers address the complexities of chronic pain
Photo by Lukasz Szyszka

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”

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