Why Smoking is a Pain in the Neck

By Pat Anson, Editor

Need another reason to stop smoking? What if you knew it was causing that pain in your neck?

That’s the conclusion of a new study being presented this week at the annual meeting of the Association of Academic Physiatrists. In a study of 182 patients who were given CT scans,  researchers found that smokers were more likely to have cervical degenerative disc disease.

“This is another example of the detrimental effects of smoking. Tobacco abuse is associated with a variety of diseases and death, and there are lifestyle factors associated with chronic neck pain,” says lead investigator Mitchel Leavitt, MD, resident physician at Emory University’s Department of Physical Medicine and Rehabilitation.

“Pain and spine clinics are filled with patients who suffer chronic neck and back pain, and this study provides the physician with more ammunition to use when educating them about their need to quit smoking.”

The cervical spine is located in the neck and is made up of bones called vertebrae. Between these bones are cervical discs that absorb shock to the spine. Through the normal aging process, these discs slowly degenerate, which means they become dehydrated and shrink.

In some cases, the drying of the disc may cause cracks and tears, through which some of the jelly-like central portion of the disc may spill out and irritate local nerves. That can result in pain in the shoulders, arms, hands and fingers.

It isn’t only wear and tear that can damage these discs. Some unhealthy habits, such as smoking, can add to cervical disc degeneration.

“Smoking is not healthy for a person’s intervertebral discs given the risk of developing microvascular disease – a disease of the small blood vessels – due to nicotine abuse,” says Leavitt. “Intervertebral discs receive their nourishment from the microvasculature that line the endplates on either side of each disc; when these blood vessels are damaged, the discs do not receive nourishment and this may speed up the degenerative process.”

While smoking has been associated with degeneration in the lumbar spine, this was one of the first studies to make the association with the cervical spine.  The patients evaluated by Leavitt and his colleagues were mostly female (57 percent), and about a third were smokers. A radiologist and a physiatrist – a physician who specializes in physical medicine and rehabilitation – reviewed their CT scans for signs of cervical degenerative disc disease. The amount of damage was rated on a scale of zero to 15.

Current smokers were found to have more cervical degenerative disc disease and were given a "damage score" that was about one point higher, on average. Not surprisingly, researchers also found that aging was associated with worsening cervical degenerative disc disease, but diabetes, hypertension, high cholesterol and high BMI were not.

Leavitt believes more research is needed on other lifestyle factors, such as high fat diets, alcohol use and obesity to see how they relate to chronic back and neck pain.

“Virtually everyone knows that moderate exercise somewhere around four to five times per week is beneficial, plus other lifestyle factors like avoidance of smoking and a proper diet are equally important. However, these topics are usually geared towards heart health, lowering blood pressure, managing diabetes, or controlling other medical conditions, and not specific to the spine,” Leavitt said. “It is one thing to live to the age of 95, and it is another to live to 95 while retaining one's mobility and being free of pain. Lifestyle medicine will likely play a large role in the future of healthcare, and having plenty of data to support lifestyle management is critical.”

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.

In a recent study published in JAMA Neurology, Swedish researchers reported that continuing to smoke after a diagnosis of multiple sclerosis significantly accelerates progression of the disease.

Chronic Pain and Weather Study Underway

By Pat Anson, Editor

The Greek philosopher Hippocrates in 400 B.C was one of the first to note that changes in the weather can affect pain levels. A large body of folklore has reinforced that belief, with expressions like “feeling under the weather” and stories about people being able to predict a storm because they “can feel it in their bones.”

British researchers are investigating that ancient theory with a modern twist, a smartphone based study called Cloudy with a Chance of Pain that aims to prove whether there is an association between pain and weather.      

“This question has been around for more than 2,000 years, but it’s only now with widespread modern technology that we have the ability to answer it,” says Dr. Will Dixon, Director of The University of Manchester’s Arthritis Research UK Centre for Epidemiology.

Anyone in the UK with arthritis or chronic pain who is over the age of 17 can participate by downloading an app from here.

The app uses a smartphone platform called uMotif that allows users to record how they are feeling, while weather data is automatically collected using their phone’s GPS.

“And we’re not just inviting people to submit data – we want their ideas about the association between weather and pain too,” says Dixon. “We will be running a big citizen science experiment where anyone can explore the data and try and spot patterns and relationships in the data. We’ll gather ideas and theories from everyone to come up the best possible conclusion.”

Participants are encouraged to record their symptoms each day until the project ends in January 2017. Even people who don’t have pain can participate by browsing through the data and submitting their own ideas. Researchers hope to compile the information and develop “pain forecasts” based on weather predictions.

“Many people with arthritis believe that changes in the weather affect the level of pain they experience, however there is currently no scientific evidence to support this relationship," said Stephen Simpson, Director of Research & Programmes at Arthritis Research UK.

“This exciting study will for the first time enable us to investigate the link between pain and the weather. We’re delighted to support this project and we hope that the use of the uMotif app will help encourage a wide group of participants to take part, both in terms of submitting their data but also examining the results themselves to help our scientists reach a conclusion."”

The weather-pain connection remains controversial. A 2014 study in Australia found that acute episodes of low back pain are not associated with weather conditions such as temperature, humidity and rain.  And a 2013 Dutch study concluded that weather has no impact on fibromyalgia symptoms in women.

You can follow the University of Manchester study on Twitter at @CloudyPain.

You can also learn more by watching this video:

Cellphone Towers Amplify Pain in Amputees

By Pat Anson, Editor

For many years there has been a debate about the possible health effects of cell phone towers, power lines and other transmission devices that create electromagnetic fields (EMFs). These magnetic and electromagnetic frequency waves pass right through us, raising concern that they might cause cancer and other adverse health effects.

A new study by researchers at The University of Texas at Dallas suggests that cellphone towers may trigger neuropathic pain, especially in amputees that suffer from phantom limb pain.

"Our study provides evidence, for the first time, that subjects exposed to cellphone towers at low, regular levels can actually perceive pain," said Dr. Mario Romero-Ortega, senior author of the study and an associate professor of bioengineering in the University's Erik Jonsson School of Engineering and Computer Science. "Our study also points to a specific nerve pathway that may contribute to our main finding."

Most of the previous research into the possible health effects of cellphone towers has been conducted on individuals with no diagnosed, pre-existing conditions. This is one of the first studies to look at the effects of EMFs on amputees.

For years, retired Maj. David Underwood noticed that whenever he drove under power lines or near other electromagnetic fields, he would feel a buzz in what remained of his left arm. When traveling by car through Texas' open spaces, the buzz often became more powerful.

"When roaming on a cellphone in the car kicked in, the pain almost felt like having my arm blown off again," said Underwood, an Iraq War veteran who was injured by an improvised explosive device (IED). His injuries resulted in 35 surgeries and the amputation of his left arm.

"I didn't notice the power lines, cellphones on roam or other electromagnetic fields until I first felt them in my arm," says Underwood.

After learning about Underwood’s experiences, Romero-Ortega decided to study the phenomena.

He and his colleagues thought that neuromas -- inflamed peripheral nerve bundles that often form due to injury – could be more sensitive to EMFs. To test their theory in a laboratory, they assigned 20 rats into two groups -- one receiving a nerve injury that simulated amputation, and the other group receiving a sham treatment.

Researchers then exposed the rats to a radiofrequency electromagnetic antenna for 10 minutes, once per week for eight weeks. The antenna delivered a power density similar to what a human would be exposed to 125 feet away from a cellphone tower.

By the fourth week, 88 percent of the rats in the nerve-injured group demonstrated a behavioral pain response, while only one rat in the sham group exhibited pain. After growth of neuroma and resection -- the typical treatment in humans with neuromas who are experiencing pain -- the pain responses persisted.

"Many believe that a neuroma has to be present in order to evoke pain. Our model found that electromagnetic fields evoked pain that is perceived before neuroma formation; subjects felt pain almost immediately," Romero-Ortega said. "My hope is that this study will highlight the importance of developing clinical options to prevent neuromas, instead of the current partially effective surgery alternatives for neuroma resection to treat pain."

Romero-Ortega says since the research produced pain responses in rats similar to those in anecdotal reports from humans such as Major Underwood, the results "are very likely" generalizable to humans.

"There are people who live in caves because they report to be hypersensitive to radiomagnetism, yet the rest of the world uses cellphones and does not have a problem. The polarization may allow people to disregard the complaints of the few as psychosomatic," he said. "In our study, the subjects with nerve injury were not capable of complex psychosomatic behavior. Their pain was a direct response to man-made radiofrequency electromagnetic energy."

At one point in the study, members of the research group showed Underwood video of subjects in the experiment and their response to radiofrequency electromagnetic fields.

"It was exactly the same type of movements I would have around cellphones on roam, power lines and other electromagnetic fields," said Underwood.

Until the study was published online in PLOS ONE, there was no scientific evidence to back up the anecdotal stories of people like Underwood, who reported neuropathic pain around cellphone towers and other technology that produce EMFs. .

Phantom limb pain is a common and painful disorder that many amputees feel after their limbs are removed. The origin of the pain and sensations from the missing limb are not well understood. There are nearly 2 million amputees in the United States, according to the Centers for Disease Control and Prevention.

Chronic Pain Changes Our Immune Systems

By Pat Anson, Editor

Scientists already know that chronic pain can change the way our brains work, but now there is new evidence that pain may also make lasting changes in our immune systems.

In studies on laboratory rats, researchers at McGill University in Montreal found that chronic pain alters the way genes work in the immune system. The discovery may help explain why pain can persist long after the initial injury.

"We found that chronic pain changes the way DNA is marked not only in the brain but also in T cells, a type of white blood cell essential for immunity,” said Moshe Szyf, a professor in the Faculty of Medicine at McGill. "Our findings highlight the devastating impact of chronic pain on other important parts of the body such as the immune system."

McGill researchers examined DNA from the brains and white blood cells of rats nine months after a nerve injury. They found a “stunning” number of changes in DNA methylation – which regulates how genes function. Chronic pain appeared to reprogram how the genes work.

"We were surprised by the sheer number of genes that were marked by the chronic pain -- hundreds to thousands of different genes were changed," adds Szyf. "We can now consider the implications that chronic pain might have on other systems in the body that we don't normally associate with pain."

Many of the genes that were altered are associated with depression, anxiety, and loss of cognition, which are some of the negative side effects of chronic pain.  The findings could open new avenues to diagnosing and treating chronic pain in humans, as some of the genes affected by chronic pain could represent new targets for pain medications.

“These findings reveal potential new avenues for the development of novel therapeutics directed at either the molecular regulation of methylation or at key genes or pathways dysregulated in chronic pain,” the study found.  “This work also provides a possible mechanistic explanation for commonly observed comorbidities observed in chronic pain (i.e anxiety, depression). Finally, the sheer magnitude of the impact of chronic pain, particularly in the prefrontal cortex, illustrates the profound impact that living with chronic pain exerts on an individual.”

The McGill study is published in the journal Scientific Reports.

A recent study at Northwestern University found that chronic pain “rewires” a part of the brain that controls whether we feel happy or sad.  Researchers found that a group of neurons thought to be responsible for negative emotions became hyper-excitable within days of an injury that triggers chronic pain.

Arthroscopic Knee Surgery Not Cost-Effective

By Pat Anson, Editor

Another study is raising doubts about the value of arthroscopic knee surgery, a procedure that is routinely used to treat osteoarthritis and other chronic knee problems. Researchers at Western University in Canada say the surgery provides no additional benefit compared to physical therapy, exercise and medication.

Over 250 million people worldwide suffer from knee osteoarthritis (OA), which causes thinning of cartilage and progressive joint damage. Nearly 40 percent of Americans over the age of 45 have some degree of knee OA.

Investigators at Western’s Bone and Joint Institute analyzed the cost-effectiveness of arthroscopic  surgery, a type of “keyhole” surgery in which the surgeon makes a small incision in the knee and inserts a tiny camera and instruments to diagnose and repair damaged ligaments or torn meniscus.

Over 850,000 arthroscopies are performed every year to relieve knee pain in the UK and the United States alone.

"We previously showed in a randomized clinical trial that arthroscopy for knee osteoarthritis provided no benefit over optimized non-operative care. Despite that finding, and subsequent similar studies, the surgery is still commonly performed," says Trevor Birmingham, the Canada Research Chair in Musculoskeletal Rehabilitation at Western's Faculty of Health Sciences. "That's why we felt it was important to do the accompanying cost-effectiveness analysis."

The two-year study, published in the journal BMJ Open, found that arthroscopic knee surgery is “not an economically attractive treatment option” compared to non-operative treatments such as physical therapy, exercise and medication. Depending on insurance, hospital charges and the surgeon, arthroscopic surgeries cost about $4,000.

“Patients who received non-operative therapies showed similar improvements in pain, function, and quality of life compared to those who also received surgery, at a significantly lower cost,” says lead author Jacquelyn Marsh, a Post-Doctoral Fellow in Health Economics at Western University.

While most people do feel better after knee arthroscopy, randomized clinical trials found that patients improve to a similar extent when they receive non-operative treatments or ‘sham’ surgery, where the patient receives anesthesia but doesn’t actually receive the surgical treatment.

“When that body of evidence is coupled with the present economic analysis, one has to question whether health care funds would be better spent elsewhere,” said Birmingham.

A 2014 report by a German health organization also found arthroscopic  surgery does not relieve pain any better than physical therapy or over-the-counter pain medications.

Another study published last year in the The BMJ called the benefit of knee surgery “inconsequential.” Researchers in Denmark and Sweden reviewed 9 studies on arthroscopic knee surgeries and found that the surgery provided pain relief for up to six months, but without any significant benefit in physical function. Risks from the surgery are rare, but include deep vein thrombosis, infection, pulmonary embolism, and death.

"It is difficult to support or justify a procedure with the potential for serious harm, even if it is rare, when that procedure offers patients no more benefit than placebo," wrote Professor Andy Carr from Oxford University’s Institute of Musculoskeletal Sciences in an accompanying editorial.

Carr said thousands of lives could be saved if the surgery was discontinued or performed less often.

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.