Spine and Hip Fractures Raise Risk of Chronic Body Pain

By Pat Anson, Editor

Breaking a bone in your spine or hip may be so traumatic that it doubles your chances of developing chronic widespread body pain such as fibromyalgia, according to a large new study by British researchers.

The study, published in the Archives of Osteoporosis, utilized an existing health database of over half a million adults to investigate associations between fractures of the spine, hip or upper and lower limbs, and the development later in life of chronic widespread body pain. Researchers at the University of Southampton also considered the possible effects of other factors, including diet, lifestyle, body build, and psychological health.

They found that men and women who had a spine fracture and women who had a hip fracture were more than twice as likely to experience long term widespread pain than those who did not have a fracture.

"The causes of chronic widespread pain are poorly characterized, and this study is the first to demonstrate an association with past fracture. If confirmed in further studies, these findings might help us to reduce the burden of chronic pain following such fractures," said lead researcher Nicholas Harvey, Professor of Rheumatology and Clinical Epidemiology at the University of Southampton.

"Chronic widespread pain is common, and leads to substantial health related problems and disability. Past studies have demonstrated an increased risk of chronic widespread pain following traumatic events, but none have directly linked to skeletal fractures."

Physical and emotional traumas have long been identified as risk factors for chronic widespread pain. For example, people involved in motor vehicle accidents are at greater risk of developing fibromyalgia, and rates of chronic widespread pain are known to increase after major disasters such as a hurricane or earthquake. Until now, there was no evidence that bone fractures could trigger such a response.

“Interestingly, the associations appeared strongest for fractures at the hip and spine, compared with fractures in the upper or lower limbs,” wrote Harvey. “High levels of morbidity and decreased survival following a hip and spine fractures is well documented, as are the potential changes in body shape, such as kyphosis, leading to pain and respiratory difficulties following vertebral fracture.”

Data for the research was collected from the UK Biobank study, which maintains records on almost everyone who utilizes the UK National Health Service.

Researchers Say Chronic Pain Rewires Brain

By Pat Anson, Editor

Researchers at Northwestern University say a brain region that controls whether we feel happy or sad is rewired by chronic pain.

Their research on laboratory rats, published in the journal Nature Neuroscience, may have also uncovered a new treatment strategy that restores the brain and dramatically lessens pain.

'It was surprising to us that chronic pain actually rewires the part of the brain controlling whether you feel happy or sad," said corresponding author D. James Surmeier, chair of physiology at Northwestern University Feinberg School of Medicine. "By understanding what was causing these changes, we were able to design a corrective therapy that worked remarkably well in the models. The question now is whether it will work in humans."

The new treatment combines a Parkinson's drug, L-dopa, and a non-steroidal anti-inflammatory drug (NSAID), both of which are FDA approved. The combined drugs target brain circuits in the nucleus accumbens and completely eliminated chronic pain behavior when administered to rodents. The key is administering the drugs together and soon after an injury.

The scientists hope to begin a clinical trial on humans to further test their theory.

"The study shows you can think of chronic pain as the brain getting addicted to pain," said A. Vania Apkarian, a professor of physiology at Feinberg. "The brain circuit that has to do with addiction has gotten involved in the pain process itself."

The researchers found that a group of neurons thought to be responsible for negative emotions became hyper-excitable within days after an injury that triggers chronic pain. This change was triggered by a drop in dopamine, a neurotransmitter.

"These results establish chronic pain cannot be viewed as a purely sensory phenomenon but instead is closely related to emotions," Apkarian said.

When scientists gave the rats the NSAID and L-dopa, which raises dopamine levels, the changes in the brain were reversed and the animals' chronic pain behavior stopped. That suggests supplementing anti-inflammatories with a medication that activates dopamine receptors or raises dopamine levels might be an effective way of treating chronic pain or preventing the transition from acute to chronic pain.

Scientists also treated the rats with another Parkinson's drug, pramipexole, which activates dopamine receptors and mimics dopamine's effect. That drug also decreased the animals' pain-like behavior.

"It is remarkable that by changing the activity of a single cell type in an emotional area of the brain, we can prevent the pain behavior," said Marco Martina, an associate professor of physiology at Feinberg.

In addition to Parkinson’s, L-Dopa is used to combat anxiety and depression, and to improve the ability to concentrate and focus. L-Dopa is sold under the brand names Levodopa, Sinemet, Madopar, Stalevo, and Prolopa.

A recent study by British researchers also found that brain chemistry is changed by chronic pain.

Researchers at the University of Manchester used PET scans to measure the spread of opioid receptors in the brains of 17 arthritis sufferers and nine healthy control subjects. The number of opioid receptors was highest in the arthritis sufferers, suggesting their brain chemistry had changed and made them more resilient to pain. That could explain why some people are better able to cope with pain than others.

The University of Manchester study is being published in Pain, the official journal of the International Association of the Study of Pain.

Genetic Defect Holds Secret to Pain Free Life

By Pat Anson, Editor

An experimental study on genetically modified mice may have uncovered a way to make low doses of opioids more effective in treating chronic pain.

Researchers at University College London are studying “transgenic” mice that were modified to carry a genetic mutation from humans who are unable to feel pain. The humans have a defect in their nervous system that prevents them from sending pain signals through a sodium channel known as Nav1.7. People born without working Nav1.7 can still feel touch normally, but not pain.

The researchers found that that mice who lack Nav1.7 produce higher than normal levels of naturally-produced opioids. Transgenic mice have twice the levels of natural opioids as unmodified mice from the same litter.

To block the effects of the natural opioids, the researchers gave the mice naloxone, an opioid blocker used in addiction treatment, and found that they became able to feel pain.

They also gave naloxone to a 39-year-old woman with the same rare mutation and she felt pain for the first time in her life.

"Studying the mice showed us what was going on in the nervous system that led to painlessness and our findings were directly translatable to humans, as confirmed by the painless patient,” said senior author Professor John Wood, University College London.

"The secret ingredient turned out to be good old-fashioned opioid peptides, and we have now filed a patent for combining low dose opioids with Nav1.7 blockers. This should replicate the painlessness experienced by people with rare mutations, and we have already successfully tested this approach in unmodified mice."

Broad-spectrum sodium channel blockers are already used as local analgesics, but they are not suitable for long-term pain management because they cause complete numbness and can have serious side-effects over time.

Opioid painkillers such as morphine are effective at reducing pain, but long-term use can lead to dependence and tolerance. As the body becomes used to opioids, they become less effective and higher doses are needed. Side effects also become more severe.

"Used in combination with Nav1.7 blockers, the dose of opioid needed to prevent pain is very low," explains Wood. "People with non-functioning Nav1.7 produce low levels of opioids throughout their lives without developing tolerance or experiencing unpleasant side-effects. We hope to see our approach tested in human trials by 2017 and we can then start looking into drug combinations to help the millions of chronic pain patients around the world."

Wood’s study is being published in the journal Nature Communications. Wood has filed for an international patent on his discovery.

Wireless LED Device Could Block Pain Signals

By Pat Anson, Editor

Researchers say a new type of implantable wireless device could revolutionize the treatment of chronic pain by using light to block pain signals before they reach the brain.

In animal studies at Washington University School of Medicine and the University of Illinois at Urbana-Champaign, researchers used implanted microLED devices to “light up” peripheral nerve cells in mice. Their study is published online in the journal Nature Biotechnology.

"Our eventual goal is to use this technology to treat pain in very specific locations by providing a kind of 'switch' to turn off the pain signals long before they reach the brain," said co-senior investigator Robert Gereau IV, PhD, a Professor of Anesthesiology and director of the Washington University Pain Center.

Unlike spinal cord stimulators, which also mask pain signals to the brain, the new devices are  soft and stretchable, and can be implanted in parts of the body that move. Spinal cord stimulators have to be anchored to bone.

"When we're studying neurons in the spinal cord or in other areas outside of the central nervous system, we need stretchable implants that don't require anchoring," said Gereau.

image courtesy gereau lab/washington university

Gereau and his colleagues are experimenting with mice that are genetically engineered to have light-sensitive proteins on some of their nerve cells. The wireless implants contain microLED lights that use “optogenetics” to activate specific nerve cells. The devices are thin, flexible, and minimally invasive because they can be implanted in soft tissue.

Earlier versions of the device used remote lighting and fiber optic delivery systems that were tethered to power sources and could not be fully implanted.

Because the new devices are small, flexible and can be held in place with sutures, they have potential uses in or around the bladder, stomach, intestines, heart or other organs, according to John Rogers, PhD, a professor of materials science and engineering at the University of Illinois.

"They provide unique, biocompatible platforms for wireless delivery of light to virtually any targeted organ in the body," said Rogers.

Rogers and Gereau designed the implants with an eye toward mass production of the devices so they could be available to other researchers. They’ve formed a company called NeuroLux to aid in that goal.

According to iData Research, the spinal cord stimulator (SCS) market was valued at $1.3 billion in 2014. The company estimates that less than 10% of potential patients are being treated with an SCS device.

Stimulators are often considered the treatment of last resort after opioid pain medication, physical therapy, steroid shots and other types of treatment fail. Many patients are reluctant to get SCS devices because the surgery is so invasive.

Rheumatoid Arthritis Raises Death Risk

By Pat Anson, Editor

Rheumatoid arthritis (RA) is not only painful and disabling – new research indicates it raises the risk of an early death, especially for patients with seropositive RA.

In a study of nearly 1,000 women with RA, researchers at Brigham and Women’s Hospital (BWH) in Boston found that RA significantly increased the women’s risk of death from cardiovascular and respiratory disease. The women are enrolled in the Nurses' Health Study, which has followed more than 100,000 female registered nurses since 1976.

"Because the Nurses' Health Study is so large and has been following participants for so long, we were able to gather much more information about our subjects - we could follow them before and after diagnosis, take their health behaviors into account and determine specific causes of death. By doing so, we found strong evidence of increased risk for respiratory, cardiovascular and overall mortality for patients with RA," said lead author Jeffrey Sparks, MD, a physician in BWH's Division of Rheumatology, Immunology and Allergy.

RA is a chronic autoimmune disease in which the body’s own defenses attack joint tissues, causing swelling, inflammation and bone erosion. Because RA is incurable, treatments focus on suppressing the immune system to reduce inflammation and slow progression of the disease.

Sparks and his colleagues evaluated 964 women in the Nurses’ Health Study and compared their mortality rates to women in the study without RA. The team controlled for other risk factors, including smoking, a known cause of respiratory and cardiovascular mortality, as well as age, body mass index, physical activity and diet.

They found that RA was associated with a 40 percent increased risk of death and that many RA patients died of chronic obstructive pulmonary disease (COPD).

Researchers also looked at differences between the two types of RA, "seropositive" and "seronegative." Patients with seropositive RA have auto-antibodies related to RA, and generally have more severe symptoms. The team found that participants with seropositive RA had nearly three times the risk of respiratory mortality than women who did not have RA. Seronegative RA was not significantly associated with increased risk of respiratory mortality.

"We found that whether participants with RA were seropositive or seronegative really mattered - those who were seropositive were at higher risk, particularly for respiratory mortality," said Sparks. "We hope that this study will encourage patients and clinicians to be more aware that patients with RA are at increased risk of both respiratory and cardiovascular mortality, particularly patients with seropositive RA."

A recent study by researchers in Mexico found that RA patients with no prior symptoms of heart disease were at higher risk of a heart attack. Their risk was higher even without other cardiovascular risk factors such as smoking and diabetes.

Many health experts believe the inflammation triggered by RA in the joints may cause inflammation throughout the body, including the heart’s coronary arteries.

According to the Arthritis Foundation, more than 50 percent of premature deaths in people with rheumatoid arthritis result from cardiovascular disease. The heightened risk of heart disease applies to all forms of arthritis, including osteoarthritis, gout, lupus and psoriatic arthritis.

Researchers Say Chronic Pain Changes Brain Chemistry

By Pat Anson, Editor

A new study by UK researchers raises an intriguing question: Does chronic pain change brain chemistry and make pain more tolerable?

The answer is yes, according to a small study at the University of Manchester. Researchers there used Positron Emission Tomography imaging (PET scans) to measure the spread of opioid receptors in the brains of 17 arthritis sufferers and nine healthy control subjects

When they applied heat to the skin of study participants to induce pain, researchers found that the more opioid receptors they had, the higher their ability was to withstand pain. The number of opioid receptors was highest in arthritis sufferers, suggesting their brain chemistry had changed in response to chronic pain.

"As far as we are aware, this is the first time that these changes have been associated with increased resilience to pain and shown to be adaptive,” said Dr. Christopher Brown. "Although the mechanisms of these adaptive changes are unknown, if we can understand how we can enhance them, we may find ways of naturally increasing resilience to pain without the side effects associated with many pain killing drugs."

image courtesy of university of manchester

It’s been known for a long time that we have receptors in our brains that respond to natural endogenous opioids such as endorphins. Those same receptors also respond to opioid pain medications.

Some people seem to cope better with pain than others, and knowing more about their resilience and coping mechanisms may lead to the development of new ways of treating pain.

"This is very exciting because it changes the way we think about chronic pain,” said Anthony Jones, a professor and director of the Manchester Pain Consortium. "There is generally a rather negative and fatalistic view of chronic pain. This study shows that although the group as a whole are more physiologically vulnerable, the whole pain system is very flexible and that individuals can adaptively upregulate their resilience to pain.

"It may be that some simple interventions can further enhance this natural process, and designing smart molecules or simple non-drug interventions to do a similar thing is potentially attractive."

Researchers at Stanford University in California have also been studying this subject, trying to learn why some chronic pain sufferers are more resilient to pain.

“I think this study emphasizes some very important points about pain resilience,” said Dr. Drew Sturgeon, a fellow in the Stanford University Pain Management Center and Stanford Systems Neuroscience and Pain Laboratory. “If you think about chronic pain as something that poses a constant challenge and requires frequent adaptation, it makes sense that we would see changes in the brain that correspond with this process.  We see it frequently from a psychological standpoint, where people are able to learn and develop better strategies for coping with pain and reduce their fear and negative thoughts about pain after dealing with it for a while.”

Sturgeon and his colleagues say resilience may also stem from an enhanced ability to enjoy the rewarding parts of life – which makes it easier to cope with pain.  

“The idea would be that if a person had more opioid receptors available they would be more sensitive to the good stuff in life, and therefore more motivated by pleasurable experiences, such as spending time with friends, exercising -- rewards that get us back on the road to living a meaningful life,” said Beth Darnall, PhD, a pain psychologist, clinical associate professor at Stanford University and author of Less Pain, Fewer Pills.

“Theoretically, people who are known to be resilient probably have more endogenous opioids -- or they have made choices in life to optimize their experience of endogenous opioids and therefore have honed an internal reward system.”

Whatever the cause of resilience, many patients hope further studies will uncover new ways of treating pain.

"As a patient who suffers chronic pain from osteoarthritis, I am extremely interested in this research. I feel I have developed coping mechanisms to deal with my pain over the years, yet still have to take opioid medication to relieve my symptoms,” said Val Derbyshire. “The notion of enhancing the natural opiates in the brain, such as endorphins, as a response to pain, seems to me to be infinitely preferable to long term medication with opiate drugs.”

The University of Manchester study is being published in Pain, the official journal of the International Association of the Study of Pain.

Study: Long-Term Opioid Use Often Ineffective

By Pat Anson, Editor

Less than half the people on long-term opioid therapy achieve relief from chronic pain, according to a new survey that found opioids even less effective in younger women. However, most respondents still considered opioids to be very or extremely helpful.

Over two thousand women and men enrolled in group health plans in Washington State and northern California were surveyed about their long-term use of opioids. The study, published in the Journal of Women’s Health, is believed to be the first to look at differences in the effectiveness of opioids between the sexes.    

Only about 20 percent of the patients on long term opioid therapy were classified as having a favorable “global pain status” – which is a measure of overall pain and function. Nearly 28% had an intermediate status and over 52% had an unfavorable global pain status.

Women between the ages of 21 and 44 were much more likely than men in the same age group to have an unfavorable status (66% vs. 40%). That finding is significant because younger women face unique risks from opioid use, such as reduced fertility and risks to a developing fetus during pregnancy.

"Given the high rates of chronic opioid use in women along with evidence of poor relief from pain and concerning risks, particularly in reproductive-aged women, we need more effective and safer options for managing pain in this population," Susan Kornstein, MD, Editor-in-Chief of the Journal of Women's Health and  Executive Director of the Virginia Commonwealth University Institute for Women's Health.

Over half the women and men with “unfavorable” pain status were depressed, unemployed, laid off or not working for health reasons.

“Our observational data indicate that for typical COT (chronic opioid therapy) patients in community practice the probability of experiencing good pain control and favorable levels of functioning is relatively low,” the study found. “However, regardless of global pain status, in every age–sex group, the majority of patients rated opioids as very or extremely helpful in relieving pain.”

Researchers admitted they could not assess whether pain and function had improved or deteriorated from the time patients began using opioids. They also could not explain why opioids appear to be more effective in men than women.

“Women tend to have greater pain severity, and are more likely to be prescribed opioids to treat their pain.  However, opioids work less well in women,” said Beth Darnall, PhD, a pain psychologist, clinical associate professor at Stanford University and author of Less Pain, Fewer Pills.

“Rather than stopping medications that are not working well, often the opioid prescriptions are continued and the dose increased—this can set women up to have more side effects and even greater pain.”

Darnall, who has studied the medical and psychological risks of long-term opioid use by women, says safer alternatives to opioids need to be found.

“For many years there was a common perception that opioids were a ‘solution’ to pain. We must continue to look beyond opioids to comprehensive treatments that have low risks for patients. Such treatments may include acupuncture, pain psychology, self-management, physical therapy, and occupational therapy.  A primary problem is lack of access to these low-risk, effective treatments.”

Drug Shows Promise for Treating Psoriatic Arthritis

By Pat Anson, Editor

An injectable drug used to treat plaque psoriasis may also be effective in treating psoriatic arthritis, according to new research published in the New England Journal of Medicine.

Secukinumab – which is sold by Novartis under the brand name Cosentyx – helped reduce swollen joints in a double-blind Phase III study involving over 600 patients with psoriatic arthritis. Treatment with Cosentyx resulted in rapid and significant improvements in about half of the patients compared to a placebo.

The study was neither large enough or long enough to evaluate side effects associated with long-term use of Cosentyx.

Psoriatic arthritis is a form of arthritis that affects about a third of people who have psoriasis — a condition that features red skin lesions. Joint pain, stiffness and swelling are the main symptoms of psoriatic arthritis, which can affect any part of the body, including the fingertips and spine.  

No cure for psoriatic arthritis exists, so the focus is on controlling symptoms and preventing further damage to joints.

Cosentyx was approved in Europe early this year as a first-line treatment for moderate-to-severe plaque psoriasis. The drug is also approved in the U.S. as a treatment for plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy (light therapy).

Novartis has applied for Cosentyx to be used as a treatment for psoriatic arthritis and ankylosing spondylitis.

Psoriatic arthritis can develop at any time, but it most commonly appears between the ages of 30 and 50, according to the National Psoriasis Foundation. Genes, the immune system and environmental factors all appear to play a role in the onset of the disease. About 10 percent of people inherit one or more of the genes that could eventually lead to psoriasis, but only 2 to 3 percent actually develop the disease.

The Link Between Empathy and Pain

Pat Anson, Editor

The Merriam-Webster dictionary defines the word empathy as “understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another.”

Or as former President Bill Clinton famously said, “I feel your pain.”

But new research suggests empathy may be a lot more complicated than we think – at least when it comes to feeling the pain of others.

A team of European researchers has found evidence that empathy may be strongly influenced by neurotransmitters in the brain -- and is not just a form of emotional or social bonding.

Their findings suggest that empathy is dependent – not on feeling the pain of others --- but on experiencing pain yourself.

“Empathy is of major importance for everyday social interaction. Recent neuroscientific models suggest that pain empathy relies on the activation of brain areas that are also engaged during the first-hand experience of pain,” wrote psychologist Clauss Lamm of the University of Vienna, lead author of a study published in Proceedings of the National Academy of Sciences.

Lamm and his colleagues recruited 100 participants for an experimental trick with a placebo. They divided the volunteers into two groups and gave one group a pill they thought was a painkiller but was actually a placebo. The second group received no pill at all.

Both groups were given a small electric shock and asked to rate the degree of pain they felt -- and the degree of pain they saw in others who were also shocked.

The group that received the placebo not only reported less pain than the control group, but they also felt there was less pain experienced by others. That placebo-empathy effect was confirmed by MRI’s – which found there was less activity in brain areas of the placebo group that felt less pain and empathy for others.

Researchers tested the placebo-empathy effect in a second study in which they used the drug naltrexone to block opioid receptors in some of the volunteers. Those given naltrexone reported feeling more pain when shocked and felt that others felt more pain as well.

"This result strongly suggests an involvement of the opioid system in placebo-empathy, which is an important step to a more mechanistic understanding of empathy,” said Lamm.

"The present results show that empathy is strongly and directly grounded in our own experiences – even in their bodily and neural underpinnings. This might be one reason why feelings of others can affect us so immediately – as we literally feel these feelings as if we were to experience them ourselves, at least partially. On the other hand, these findings also explain why empathy can go wrong – as we judge the feelings of others based on our own perspective,” explains Lamm.

Lamm and his colleagues are now working on a follow-up study in which they are investigating the effects of opioids on empathy.

Blood Test Identifies Women Prone to Migraine

By Pat Anson, Editor

Researchers may have discovered a new marker for episodic migraine – lipids in the blood that regulate inflammation in the brain.

In a small study involving 88 women, researchers found that total levels of the lipids -- called ceramides or sphingolipids -- were significantly decreased in women with episodic migraine when compared to women without migraine. Episodic migraine is defined as less than 15 headaches per month. The women in this study had an average of 5.6 headache days a month.

"While more research is needed to confirm these initial findings, the possibility of discovering a new biomarker for migraine is exciting," said study author B. Lee Peterlin, DO, with the Johns Hopkins University School of Medicine. The study is published in Neurology,  the medical journal of the American Academy of Neurology.

Ceremides are bioactive lipids that may be involved in other neurological disorders, such as dementia and multiple sclerosis.

Women with migraine had approximately 6,000 nanograms per milliliter of ceramides in their blood; while women without headache had about 10,500 nanograms. Every standard deviation increase in total ceramide levels was associated with over a 92% lower risk of having migraine. Two other types of lipids, called sphingomyelin, were associated with a 2.5 times greater risk of migraine.

The researchers tested their theory by analyzing the blood of a random sample of 14 of the women. They were able to correctly identify those who had migraine and those who did not based on their lipid levels.

"This study is a very important contribution to our understanding of the underpinnings of migraine and may have wide-ranging effects in diagnosing and treating migraine if the results are replicated in further studies," said Karl Ekbom, MD, with the Karolinska Institute in Stockholm, Sweden, who wrote an accompanying editorial.

Ekbom noted there were limitations in the study. Only women were included, chronic migraine was not studiedm and an unusually high number of participants had migraine with aura

Migraine is thought to affect a billion people worldwide and about 36 million adults in the United States, according to the American Migraine Foundation. It affects three times as many women as men. In addition to headache pain and nausea, migraine can also cause vomiting, blurriness or visual disturbances, and sensitivity to light and sound.

Smoking Accelerates Multiple Sclerosis

By Pat Anson, Editor

Smoking is never a good idea for anyone – especially people in chronic pain -- but according to a new study it is particularly bad for multiple sclerosis patients, both before and after diagnosis.

Cigarette smoking is already a known risk factor for developing multiple sclerosis (MS), but in a first of its kind study published in JAMA Neurology, Swedish researchers found that continuing to smoke after diagnosis significantly accelerates progression of the disease.

MS is a chronic and incurable disease which attacks the body’s central nervous system, causing numbness in the limbs, difficulty walking, paralysis, loss of vision, fatigue and pain. Symptoms begin with a series of irregular relapses, and after about 20 years MS worsens into a secondary progressive (SP) stage of the disease.

In a study of over 700 MS patients who continued to smoke after their diagnosis, researchers found that each additional year of smoking accelerated the time to SP conversion by 4.7 percent.  

Looking at it another way, the study found that patients who continued to smoke converted to SP faster (at an average age of 48) than those who quit smoking (at age 56).

“This study demonstrates that smoking after MS diagnosis has a negative impact on the progression of the disease, whereas reduced smoking may improve patient quality of life, with more years before the development of SP disease,” said lead author Jan Hillert, MD, Department of Clinical Neuroscience, Karolinska University Hospital Solna in Stockholm.

“Evidence clearly supports advising patients with MS who smoke to quit. Health care services for patients with MS should be organized to support such a lifestyle change.”

Getting MS patients to quit is important not only for patients, but for society as a whole because of the high cost of treating MS. Disease modifying drugs such as fingolimod and natalizumab, cost about $30,000 per year and are not always effective.

“This study adds to the important research demonstrating that smoking is an important modifiable risk factor in MS. Most importantly, it provides the first evidence, to our knowledge, that quitting smoking appears to delay onset of secondary progressive MS and provide protective benefit,”  said Myla Goldman, MD, of the University of Virginia, and Olaf Stüve, MD, of the University of Texas Southwestern Medical Center in an accompanying editorial in JAMA Neurology.

Previous studies have found that smoking increases your chances of having several types of chronic pain conditions.

A study of over 6,000 Kentucky women found that those who smoked had a greater chance of having fibromyalgia, sciatica, chronic neck pain, chronic back pain and joint pain than non-smokers. Women in the study who smoked daily more than doubled their odds of having chronic pain.

A large study in Norway found that smokers and former smokers were more sensitive to pain than non-smokers. Smokers had the lowest tolerance to pain, while men and women who had never smoked had the highest pain tolerance.

Discovery Could Lead to Earlier RA Treatment

By Pat Anson, Editor

Scientists have discovered a new protein that regulates the severity of tissue damage caused by rheumatoid arthritis, a finding that could help identify RA patients earlier for more aggressive treatment.

The protein – known as C5orf30 – was found in DNA and biopsy samples from the joints of over 1,000 RA patients in the UK and Ireland.

"Our findings provide a genetic marker that could be used to identify those RA patients who require more aggressive treatments or personalized medicine," said Professor Gerry Wilson from the School of Medicine and Medical Science, University College Dublin, who led the research.

"They also point to the possibility that increasing the levels of C5orf30 in the joints might be a novel method of reducing tissue damage caused by RA".

Rheumatoid arthritis is a chronic autoimmune disease in which the body’s own defenses attack joint tissues, causing joint pain, inflammation and bone erosion. About 1.5 million Americans and 1% of adults worldwide suffer from RA.

"These exciting findings will prompt us to further explore the role of this highly conserved protein that we know so little about, and its significance in human health and disease,” said co-author Dr. Munitta Muthana from the Medical School at the University of Sheffield.

The study, funded by Arthritis Ireland and the University of Sheffield, is published in the journal PNAS.

It is estimated that 30% of patients with rheumatoid arthritis are unable to work within 10 years of onset of the disease. It affects more women than men, and often more severely. RA is most common between the ages of 40 and 70, but it can affect people of all ages, including children.

Although there is no cure for RA, new drugs are available to treat the disease and slow joint damage. Self-management of the condition by patients, including exercise, is also known to reduce pain and disability.

One of the biggest problems in treating RA is early diagnosis and treatment, which can reduce the amount of joint damage.  

"Treatments for arthritis have improved enormously over the last number of years. Thirty years ago, rheumatologists' waiting rooms were filled with people in wheelchairs. Today, that is no longer the case. The outlook for a person diagnosed with arthritis in 2015 is much brighter than it used to be,” said John Church, CEO of Arthritis Ireland.

British researchers recently said they were close to developing a blood test that could detect both RA and osteoarthritis in its earliest stages.

Osteoarthritis (OA) is a progressive joint disorder caused by painful inflammation of soft tissue, which leads to thinning of cartilage and joint damage in the knees, hips, fingers and spine.

Researchers at the University of Warwick’s Medical School identified a biomarker linked to both forms of arthritis. Diagnostic blood tests already exist for RA, but the newly identified biomarker could lead to one which can diagnose both RA and osteoarthritis.

“This discovery raises the potential of a blood test that can help diagnose both RA and OA several years before the onset of physical symptoms," said lead researcher Naila Rabbani, PhD.

Rabbani’s research focused on citrullinated proteins (CPs), a biomarker present in the blood of people with early stage rheumatoid arthritis. Patients with RA have antibodies to CPs and the Warwick researchers established for the first time that CPs levels also increase in early-stage OA.

That research is published online in Nature Scientific Reports.

Debate Grows over Spinal Injections

By Pat Anson, Editor

A controversial government funded study critical of epidural steroid injections has been republished in the Annals of Internal Medicine, fueling a growing debate over the effectiveness and safety of spinal injections.

A prominent pain specialist called the study’s publication in a peer-reviewed journal “an insult to thousands of physicians across the world."

In a systematic review of 30 placebo controlled trials, researchers found that epidural steroid injections (ESI’s) offer limited or no relief from radiculopathy and spinal stenosis, two conditions that cause low back pain. The study was funded by the Agency for Healthcare Research and Quality (AHRQ) and conducted at the request of the Centers for Medicare and Medicaid Services.

“Epidural corticosteroid injections for radiculopathy were associated with early improvements in some outcomes versus placebo interventions, but effects were small and unsustained, and epidural corticosteroid injections had no clear effects in patients with spinal stenosis,” wrote lead author Roger Chou, MD, a Professor at Oregon Health & Science University (OHSU) School of Medicine and a staff physician in the Internal Medicine Clinic at OHSU.

Epidural injections using analgesics have long been used to relieve pain during childbirth, but spinal injections with steroids are also widely used for back pain. Although the Food and Drug Administration has never approved the use of steroids to treat back pain, several million ESI’s are performed “off label” in the U.S. annually.

The shots have become a common and sometimes lucrative procedure at many hospitals and pain management clinics. Costs vary from a few hundred dollars to over $2,000 per injection.

“Evidence on the effects of using different approaches, corticosteroids, or doses on effectiveness of epidural corticosteroid injections was limited, but indicated no clear effects,” said Chou, who was the principal investigator and author of several other studies published in peer reviewed journals.

“It is a travesty that Chou et al continue to publish these types of manuscripts. It is an insult to thousands of physicians across the world who perform these procedures and millions of patients who have received relief from them,” said Laxmaiah Manchikanti, MD, chairman and CEO of the American Society of Interventional Pain Physicians.

Manchikanti, who is medical director of a pain clinic in Paducah, Kentucky, conducted several of the studies reviewed by Chou and his colleagues.

“Consumers need to understand that the design of their systematic review is flawed and that significant bias exists in the reporting of the results,” Manchikanti wrote in an email to Pain News Network. “It is like eating 2 bananas from different countries and saying both are equally sweet, so neither is sweet. They also are looking for the differences in improvement between both groups rather than how a patient has improved from before the treatment to after the treatment."

Chou’s study also came under fire when it was released by the AHRQ. The Multisociety Pain Workgroup (MPW), a coalition of 14 different societies representing anesthesiologists, surgeons and pain management doctors, sent a lengthy letter to the AHRQ, calling the report's analysis on the effectiveness of ESI's "flawed” and “absurd.”  .

"I don't think its surprising that people who do these injections might disagree or not be happy with the results. Some of the comments seem to demonstrate a poor understanding of how to look at interventions in scientific research," Chou told Pain News Network. "I think people are afraid that they're not going to get paid for doing these types of things. It's not surprising, when people's pocketbooks are threatened, this how they respond."

Chou and his colleagues found the only significant benefit of ESI’s was temporary relief from back pain that usually lasts for only a few days. He attributes much of the pain relief to a placebo effect.

"It's clear that interventions for back pain have a very high placebo effect. We've known that for decades and its been demonstrated over and over again," said Chou.

Manchikanti says most of his patients get pain relief that lasts for several weeks.

“Each patient should be selected individually. They should understand the risks and the off-label nature of these drugs in the epidural space,” he said. “Epidural corticosteroids have been shown to be risky, come with a warning from the FDA, and are an off-label use of these powerful anti-inflammatories.

“For a patient, if they choose to have the procedures done with local anesthetic alone, or with local anesthetic and steroids, they should measure their progress. If they do not improve with the first procedure, they should carefully think about the second procedure; however, there is no reason to have any more than 2 procedures if they do not improve.”

The Choosing Wisely campaign of the ABIM Foundation, which seeks to reduce or eliminate unnecessary medical procedures, also recommends that doctors do not to repeat the injection if a patient shows no sign of improvement.

A number of prominent pain doctors have told Pain News Network the shots are overused, with some patients getting dozens of injections.  

Terri Anderson says repeated shots gave her temporary pain relief from a bulging disc in her back.

“I did receive immediate and short-term benefits over a 3 year time frame. However, I am here to tell you that the injections did not save me from surgery as the disc ultimately failed,” she said.

Anderson now suffers from arachnoiditis, a chronic and painful inflammation of the spinal column that has left her permanently disabled. The Hamilton, Montana woman believes the condition was brought on by too many injections.

“If I had the opportunity to go back in time, I would have stayed away from intervention and lived with the pain I had which was chronic, but it was manageable,” Anderson said.

“The government and professional medical societies have been keeping chemically induced adhesive arachnoiditis hidden from public awareness. Why is that? There is too much profit at stake for hospitals and pain clinics throughout the country. If a physician were to provide their patients with true informed consent (and explain the horrors of arachnoiditis), then no one in their right mind would undergo an epidural steroid injection.”

Researchers Say Back to School Headaches Often Real

By Pat Anson, Editor

With summer nearly over and millions of children heading back to school, many parents will hear a familiar refrain:

“I’ve got a headache. Can I stay home from school?”

While parents may be tempted to think their child dreads going back to school and just wants to prolong summer a little longer, kids now have research to back them up.

In a study of emergency room visits by children, researchers at Nationwide Children’s Hospital in Columbus, Ohio found that pediatric headaches do indeed increase in the fall – often because children are stressed out by abrupt changes in their summer routines, nutrition and sleep patterns.

“When we saw many of our families and patients in clinic, the families would report that their child or teenager’s headaches would increase during the school year,” said lead researcher Ann Pakalnis, MD, a neurologist and Director of the Comprehensive Headache Clinic at Nationwide Children’s Hospital.

“So, we decided to go back and look at emergency department visits for that time period and see if there were more visits here at certain seasonal variations during the year.”

Pakalnis and her colleagues analyzed about 1,300 emergency room visits to the hospital by children from 2010 to 2014. The number of pediatric headaches was stable throughout the year, except for the fall – when headaches in school aged children surged by nearly a third.

"We see a lot of headaches in young boys, from five to nine years of age, and in boys they tend to get better in later adolescence,” said Pakalnis, who is also a professor of Clinical Pediatrics and Neurology at The Ohio State University College of Medicine. “In teenage girls, migraines oftentimes make their first presentation around the time of puberty and unfortunately tend to persist into adulthood.”

The two types of headaches seen most often by physicians are tension headaches and migraines. About 20 percent of all pediatric patients 11 years and older suffer from migraine, which are often associated with nausea and vomiting, as well as sensitivity to light, sound and smell. Tension headaches tend to feel more like a painful tightening around the head.

The increase in fall headaches may be attributed to a number of factors, including academic and social stress, schedule changes and an increase in extracurricular activity. Other common headache triggers include lack of sleep, too much caffeine, lack of exercise and too much time on a computer or mobile device.

Researchers say headaches can often be prevented, just by getting three meals a day, drinking enough liquids, and getting adequate sleep.

“Your brain is like your cell phone,” said Howard Jacobs, MD, a headache specialist at Nationwide Children’s. “If you don’t plug your cell phone in, it doesn’t have energy, it doesn’t work well. If you don’t plug your brain in by providing energy, it doesn’t work well and that causes headaches.”

If headaches persist or get worse, Jacobs says a doctor should be seen.

“A sudden, severe headache or a change in the headache sensation from previous, what we call ‘first or worst’ headaches should be evaluated,” said Jacobs. “Another good rule of thumb is that if the headaches are interfering with a child’s normal routine, then it is time to get them evaluated, so therapy can be instituted to return your child’s life to normal.”

Nationwide Children’s Hospital produced this video about the headache study:

Findings from Nationwide Children's Hospital physicians demonstrate that headaches increase in fall in children, a trend that may be due to back-to-school changes in stress, routines and sleep.

For tension headaches, doctors say over-the-counter pain relievers such as acetaminophen, ibuprofen or naproxen can be helpful, but they can make headaches worse if taken too often.

Until recently, treatment options have been limited for children with migraine.

In May, the U.S. Food and Drug Administration approved Treximet for pediatric migraine patients 12 years of age and older. Treximet is the first approved prescription drug for migraine to contain both sumatriptan and naproxen. Sumatriptan is a triptan that works in the brain by reducing vascular inflammation. Treximet was approved by the FDA for use by adults in 2008.

In June, the FDA also approved Zomig nasal spray for the treatment of migraine in pediatric patients 12 and older. Zomig provides pain relief in as little as 15 minutes, with most patients obtaining some relief in about two hours. Zomig was approved for use by adults in 2003.

New Stimulator Delivers Back Pain Relief

By Pat Anson, Editor

A new type of spinal cord stimulator (SCS) provides significantly more relief from chronic back and leg pain than traditional SCS therapy, according to the results of a new study published in the journal Anesthesiology.

The Senza spinal cord stimulator, which recently won approval from the U.S. Food and Drug Administration, uses high frequency pulses of 10,000 Hz to mask a patient’s perception of pain. Traditional SCS therapies use frequencies of 40 to 60 Hz.

"This is the first long-term study to compare the safety and effectiveness of high frequency and traditional SCS therapy for back and leg pain," said lead author Leonardo Kapural, MD, professor of anesthesiology at Wake Forest University School of Medicine and clinical director at the Carolinas Pain Institute.

"Chronic back and leg pain have long been considered difficult to treat and current pain relief options such as opioids have limited effectiveness and commonly known side effects. Given the prevalence of chronic pain, high frequency SCS is an exciting advance for our patients."

image courtesy of nevro

In a study of 171 patients with implanted SCS devices, 85 percent of those with back pain and 83 percent with leg pain using the Senza HF10 stimulator had a 50% reduction in pain or greater after three months.

Only about half the patients implanted with a traditional SCS device (44% with back pain and 56% with leg pain) experienced that kind of pain relief.

None of the patients in the HF10 therapy group experienced paresthesia – a tingling or buzzing sensation often felt with lower frequency stimulators. They were also more likely to be “very satisfied” with their pain relief (55% versus 32%).

Lower back pain affects about a quarter of the world’s adult population and is the leading cause of disability. Back pain is usually treated with physical therapy or pain relievers.

For chronic back pain, spinal cord stimulators are often the treatment of last resort because the devices have to be surgically placed near the spine and connected to batteries implanted under the skin. The devices send electrical impulses into the spine to mask pain.

The Senza SCS system is made by Nevro (NYSE: NVRO), a medical device company based in Menlo Park, California. Senza has been available in Europe and Australia for the last five years. In May, Senza won approval from the FDA for use in the United States.

MarketsandMarkets, a market research firm based in Dallas, estimates the global market for spinal cord stimulators and other neuromodulation devices could reach $6.8 billion by 2017.