Addicted to Pain?

Some brains may be wired to become addicted to pain.  In fact, researchers have been able to accurately predict people who will continue to experience back pain more than a year after their initial injuries.

A study done at Northwestern University in Illinois looked at 39 people with recent onset of back pain.  Half still had pain a year later—their original pain had converted into insidious, chronic pain.  All participants had similar pain at the start of their injuries, but the chronic pain cohort had an unusually strong connection between two regions of the brain: the nucleus accumbens and the prefrontal cortex.

The two regions seemed to work in tandem, if one was active the other also “lit up.” A stronger connection correlated with a higher likelihood of developing chronic pain.

“We’re very excited about these results,” observed study coauthor A. Vania Apkarian of Northwestern. “We think they open up a whole new way of looking at chronic pain.” The research was presented in the July 1, 2012 Nature Neuroscience online journal.

Previous studies have examined brain differences in chronic pain sufferers, but researchers had not been able to discern whether these changes were caused by the chronic pain or an effect of living with it.  This study was the first to reveal a predictive signal present in the brain before the pain becomes chronic.

Interestingly, the study may link chronic pain development to the brain’s addiction conduit since both include the nucleus accumbens.  “This is certainly part of the addiction pathway,” Apkarian noted, observing that though the idea hasn’t been tested, chronic pain may stem from the brain essentially becoming addicted to pain and warrants further study.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 26.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Shingles Overview

What is Shingles?

After a person has had chicken pox the virus that causes it stays sleeping for decades in nerves near the spine.  The virus is herpes zoster.  About 20% of people who have had chicken pox will later have a shingles outbreak.  Shingles usually affects older people and people with weak immune systems.

Cold sores on the lips and genital herpes are caused by different herpes viruses, herpes simplex viruses.

Symptoms

If the virus wakes up, it travels along nerve fibers to the skin, usually appearing in one area, on one side of the body, and along the line of a nerve.  But shingles can be anywhere on the body.  The rash is painful and has fluid-filled blisters.  The first symptoms start 1 to 5 days before the rash and include:

• Itching
• Tingling
• Burning sensation
• Pain, sometimes worse at night

Less common symptoms are fever, chills, headache and stomach ache.  Shingles near the eye or ear can cause vision or hearing loss and are usually treated aggressively.

The blisters usually scab over in 7 to 10 days and disappear completely in 2 to 4 weeks.  In most people the rash leaves no scars and the pain and itching go away after a few weeks or months.

In some people the pain from shingles stays for months or even years after the rash is gone.  The pain is from damage to the nerves in the skin.  This is called post-herpetic neuralgia. 

Treatment

There is no cure for shingles.  But there are antiviral medications that can make the episode shorter and milder if given early.  They also reduce the risk of pain after the rash is gone.  The antiviral drug should be started at the first sign of symptoms to be most effective.

Over-the-counter pain and itch medicines, such as calamine lotion, work fairly well for many people.  If the pain is severe or the rash is near the eye or ear, the doctor may prescribe steroids to reduce the inflammation.  Using a compress dampened with cool water may help with itching.  Scratching should be avoided to prevent damage to the skin and to prevent breaking the blisters.

Vaccine

A shingles vaccine is available.  It prevents about half of shingles cases and reduces the frequency of post-shingles pain.  The Centers for Disease Control recommend that all adults 60 years and older be vaccinated.  The vaccine does not work well in people over 80 and is generally not recommended for this age group.

Is It Contagious?

Yes, but you can’t get shingles from another person; only chicken pox.  If you have never had chicken pox, or the vaccine for it, and you are then exposed to the fluid in the shingles blisters, you can get chicken pox.

Caregivers can carry the virus from one person to another and if the second person has not had chicken pox, they may get it.  Shingles can only be transmitted when the blisters have burst and are oozing, before they crust over. 

What can you do to prevent spread?

• Prevent blisters from breaking open.
• Keep the rash covered to prevent the blister fluid from contaminating others. 
• Assist the resident with shingles to wash hands often. 
• Only caregivers who have already had chicken pox should be assigned to residents with shingles. 
• No one who is pregnant should be assigned to a resident with shingles.
• Keep surfaces clean and disinfected.
• If the resident has shingles on the buttocks, he or she should not use common toilets.
• All caregivers and housekeepers should wear gloves in the resident’s room until he is no longer contagious.  Hands should be washed after removing gloves.
• Determine if roommates or others the resident socializes with are at risk.
• Use common sense precautions.
• Washing Linens

People handling sheets and towels of a person with shingles should wear gloves.  Sheets and towels should not be shaken or set down on a surface, even the floor.  They should immediately be put into a linen bag.  No special procedures are needed for washing linens.

Staff with Shingles

Staff members who have shingles should not care for vulnerable residents, including people with cancer, residents with compromised immune systems or those who have not had chicken pox. 

This article was originally published in Pathways & Partners Newsletter - Issue 27.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Distractions Cut Pain

It is established that distracting mental activities can minimize perception of pain, but how this happens has not been well understood.  A study published in Current Biology online has found that it is related to a spinal process involving opioid neurotransmission.

A study of 20 men with an average age of 27 found that distraction not only takes the focus away from the pain, but can dampen the body’s initial physiological response to pain through endogenous opioids.
Painful levels of heat were administered to the subject while undergoing functional MRIs.  Those doing complex memory tasks were pre-occupied to the extent that they experienced 19% less pain than those doing simpler mental tasks.

“This phenomenon is not just a psychological phenomenon, but an active neuronal mechanism reducing the amount of pain signals ascending from the spinal cord to higher-order brain regions,” said lead author Christian Sprenger, of the University Medical Center Hamburg-Eppendorf in Hamburg, Germany.

Sprenger and his colleagues repeated the experiment with another group of 15 men, average age 25.  This time they administered naloxone to block opioid effect or saline solution.  Perception of pain was 40.5% greater for those with the difficult cognitive task when given the opioid antagonist naloxone. This provided the evidence that endogenous opioids play a role in the distraction phenomenon.

“Our findings strengthen the role of cognitive-behavioral therapeutic approaches in the treatment of pain diseases, as it could be extrapolated that these approaches might also have the potential to alter the underlying neurobiological mechanisms as early as in the spinal cord,” Sprenger and colleagues concluded.  

For more information see the May 17, 2012 online issue of Current Biology.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Romance Reduces Pain

New Love

The dizzy stage of early romantic love seems to reduce the sensation of physical pain.  So say the results of research at Stanford University School of Medicine.  The participants reported significantly lower levels of pain when looking at pictures of their beloved than when viewing photos of friends.

“Love engages very deep primitive reward systems that directly impact on our overall experience of pain,” says researcher Sean Mackey, whose team looked at the effects of romantic feelings on pain.

Fifteen students, aged 19-21, who were in the first nine months of a romantic relationship and described themselves as “intensely in love” were recruited for the experiment.  They were instructed to bring a photo of their sweetheart as well as one of a good-looking acquaintance of the same sex as the sweetheart.

While sitting in an MRI scanner to record their brain activity, the students held a block whose temperature could be controlled to cause high, moderate or no pain.  Their pain ratings were noted while focusing on the picture of their loved one, the acquaintance, and a word-puzzle distraction.

Both the photos of romantic partners and the distraction puzzle reduced pain by nearly identical amounts.  But the students had significantly less pain relief when looking at the photos of the attractive acquaintance.

Although the sweetheart photos and word puzzles both provided relief, they worked in different parts of the brain.  The part of the brain activated by love was the brain’s reward center which is also activated by chocolate and drugs like cocaine.

It turns out that the writers of all those romantic songs and poems were right—love truly is a powerful thing.

This article was originally published in Pathways & Partners - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Music Can Mean Less Pain

Focusing on music can distract people who have significant anxiety about pain enough that they feel the pain less acutely, according to a recent study done at the University of Utah Pain Research Center.  The study found that pain was reduced as the demands of focusing on the task rose.

Researchers had 153 volunteers concentrate on following a melody so they could identify the tones that stood out.  During the session small pain shocks were administered through fingertip electrodes.  The authors explained that the effects of the music resulted from competition with the participants’ pain pathways.

Interestingly, those who had registered the most anxiety about pain became more absorbed in the task and were more likely to experience reduced perception of pain.  The study authors suggested that, “Clinicians should consider patients’ personality characteristics when recommending behavioral interventions like music listening for pain relief.”

Pathways has volunteers that can provide music sessions to our hospice patients as part of our Integrative Therapies program of care for body and soul.

The results were published in the December, 2011 issue of the Journal of Pain.

Managing Pain Without Medication

In addition to medication for pain, there are other things we can do to reduce pain.  Usually these are used in addition to medicine or while waiting for the medicine to work.  But if a resident refuses pain medication, using these techniques may help.

Alternatives to Try

Distraction:  This is an effective technique.  It’s as though the brain can only pay attention to one thing at a time.  Talking, watching TV, playing games or looking at photo albums are some examples.  If the pain is severe, these will not work.

Deep breathing / relaxation exercises:  Guide the person in deep, slow, rhythmic breathing.  There are many relaxation recordings available that are easy to follow.  You can suggest to family members that they purchase relaxation recordings and furnish a listening device.

Cold:  A cold pack (gel pack, ice pack, or zip bag with crushed ice) helps inflammation or muscle ache.  Wrap the pack in a towel; do not put the ice pack directly on the skin.  Even if this does not relieve all pain, it may help to numb the area somewhat.

Warmth:  A warm tub bath or warm packs can relax muscles that have tightened due to pain.  A warm, wet washcloth applied directly to the affected area may help.  Covering the cloth with plastic will help retain the heat longer.

Massage: This is an excellent way to distract from pain and relax tense muscles that make the pain worse.  Lotion may reduce friction.  You do not have to massage the painful area.  Massaging another area of the body may distract the mind from pain.

Prayer / meditation: Some people find this very comforting and perceive less pain during prayer.  There may also be rites or rituals that could comfort the resident.  Ask family members about this.

Music: Music is another form of distraction that research has shown relieves pain.  It does not matter what kind of music, whatever the resident likes will work.  Again, family members can help provide information about musical tastes and recordings and a CD player.

Energy work / therapeutic touch: These are hands-on techniques in which the practitioner places his or her hands on the resident’s clothed body to achieve a transfer of energy.

Acupressure / acupuncture: These techniques apply pressure or needles to specific points on the body to relieve discomfort in other areas that are associated with those points.

Reflection / life review: Those nearing the end of life often want to reflect on the events of their lives and the people they knew.  Asking about family members or the resident’s youth or birth place may assist in starting this kind of life review.

Pets: Research shows that pets improve mood, lower blood pressure and heart rate, and may serve as a good distraction from pain.

Innovative Program at Pathways

Pathways Hospice patients can take advantage of our well developed Integrative Therapies program.  It provides innovative therapies such as guided imagery, comfort touch, music therapy, aromatherapy, massage, and pet therapy.  These therapies are shown to reduce agitation in residents.

If you are interested in learning more about the Integrative Therapies program at Pathways, talk to Pathways staff, or visit our website:  www.pathwayshealth.org.  The Resources section includes downloadable information and simple tips for incorporating Integrative Therapies in your daily life too!

Men, Women, and Pain

Rigorous research has concluded that men have a higher threshold for pain.  In a large-scale prospective study of 700 patients conducted by physicians from Tufts-New England Medical Center and San Ignacio Hospital, Bogata, Colombia, researchers examined post-surgical morphine use.  After adjusting for type of surgery and age, women had higher levels of pain intensity throughout the study than men, requiring an average of 30% more morphine on a per-weight basis than men to attain a similar decrease in pain intensity. 

Research results have been mixed, some finding that men required more morphine after surgery than women.  A very large Chinese study found women used significantly less morphine when using patient-controlled analgesia post-operatively, indicating that cultural, ethnic or genetic factors may account for differing research results.  But in animal models, male rats exhibited greater analgesia than female rats to equal doses of opioids.

The researchers wrote that, “Sex differences in pain perception have been attributed to a different socialization process for men and women that influences bodily experience and the willingness to communicate distress. Hormone variations could also in part explain sex differences in pain experience and response to morphine.”

Power of Positive Thinking

A series of lab experiments conducted in Europe found that those patients who expect their analgesics to work get relief from their pain.  Those who were told their painkillers had been discontinued had more pain, even though they were actually continuing to receive the same dose. A patient’s expectations about the effectiveness of a pain drug appear to override the properties of the drug itself.

Scans Illustrate Phenomenon

Patient MRI scans conducted during the research show that, “volunteers had more activity in areas of the brain involved in memory and anxiety when they were expecting pain versus when they were expecting relief.  When the volunteers were told the drug would work, there was a boost in brain activity in areas associated with fighting pain,” says study author Dr. Ulrike Bingel, from the department of neurology at the University of Hamburg Medical Center in Germany.

Although the placebo effect is well documented, there is less research on the “nocebo” effect, in which patients have negative experiences when warned about the side effects or lack of effectiveness of a treatment, even if they are taking a placebo.

“This tells me that when we’re talking to patients and presenting therapy, the more positive we are about how the therapy is going to impact them, the better outcomes we’re going to have,” says Carla Rubingh, a pain management specialist and assistant professor of pharmacy practice at the University of Nebraska Medical Center in Omaha who was not involved in the study. 

Benefits of the Mind-Body Connection

Pathways is home to an innovative Integrative Therapies Program that includes guided imagery and meditation to help patients find comfort and relief.  Relaxation techniques use the mind-body connection to achieve relaxation. Using simple suggestions, the practitioner guides the patient or family member to make the changes they wish to achieve in their physical or emotional state. This is very effective in reducing stress and anxiety, and is helpful in pain management.

For more information about Integrative Therapies at Pathways visit our website and Integrative Therapies resource page for caregivers. 

Swearing Makes Pain More Tolerable

Uttering a curse word when you stub your toe or hit your thumb with a hammer could actually make it easier to bear the pain. Swearing is a common response to pain, but until now there has been no research looking into this. 

"Swearing has been around for centuries and is an almost universal human linguistic phenomenon," said Richard Stephens of Keele University in England, and one of the authors of the study.

Stephen’s team thought swearing would exaggerate the pain and people would tolerate it less.  The opposite turned out to be true.

The researchers had 64 university students put their hands in a tub of ice water for as long as possible while repeating a swear word of their choice.  The experiment was then repeated with the volunteers repeating a more common word that they would use to describe a table.

Contrary to what the researchers expected, the volunteers kept their hands submerged longer while repeating the swear word.

A Primal Response

Stephens says that swearing comes from deep-seated, primal, emotional brain centers.  Just as a cat would screech if his tail as stepped on, a primate would make a noise, and in humans our language ability often transforms the screech into a swear word. 

The researchers think that the increase in pain tolerance occurs because swearing triggers the body's natural "fight-or-flight" response. Stephens and his colleagues suggest that swearing may increase aggression (seen in accelerated heart rates), which downplays weakness to appear stronger.

"Our research shows one potential reason why swearing developed and why it persists," Stephens said.

The results of the study are detailed in the Aug. 5, 2009 issue of the journal NeuroReport. This article is adapted from the Live Science website.

For more information about Pathways Home Health, Hospice & Private Duty please visit our website at www.pathwayshealth.org.