News & Research Archive — Here is a history of past Research for 2009, 2008 or 2007

One of the most frustrating pain symptoms to manage for people suffering with chronic pain conditions is neuropathic pain. According to Wikipedia neuropathy is defined as "disorders of the nerves within the peripheral nervous system (specifically excluding encephalopathy and myelopathy, which pertain to the central nervous system.) It is usually considered equivalent to peripheral neuropathy, which is defined as deranged function and structure of peripheral motor, sensory, and autonomic neurons, involving either the entire neuron or selected levels. According to some sources, a disorder of the cranial nerves can be considered a neuropathy."

Unfortunately for people living with neuropathic pain, they are often prescribed opiates, which in most cases are contraindicated for this type of pain symptom. I recently discovered a new internet resource called RedOrbit.com. The RedOrbit Knowledge Network is an online community specifically for those with an interest in science, space, health and technology. On that site I found an article titled Engineered Viral Vectors Target Painful Nerve Diseases. Excerpts are posted here and if you wish to review the entire article, visit the RodOrbit.com site.

Specially designed virus-derived vectors – engineered not to cause disease – can take therapeutic genes to the malfunctioning peripheral neurons outside the spinal cord and brain, alleviating the pain and other dysfunction that can result from a chronic disease or drug treatment, said researchers from Baylor College of Medicine and the University of Glasgow in a report in the current issue of the Journal of Clinical Investigation.

“The challenge is to deliver the beneficial genes specifically to the diseased nerve cells, or ‘neurons’, and not to the neighboring unaffected cells or tissues,” said Chan. To correct this problem, Chan and his colleagues generated special “helper-dependent” adenoviruses that attach only to dorsal root ganglion neurons. He and his colleagues found that their adenovirus took the missing Hexb gene to the malfunctioning nerves and corrected the problem with high efficiency.

Many pain management practitioners use certain antidepressants e.g. tricyclics and selective serotonin-norepinephrine re-uptake inhibitors (SNRI's), anticonvulsants, especially pregabalin (Lyrica) and gabapentin (Neurontin), and topical lidocaine. Opioid analgesics and tramadol are sometimes used, but are not recommended as a first line of treatment. Many of the pharmacologic interventions for chronic neuropathic pain decrease the sensitivity of nociceptive receptors, or desensitize C fibers such that they transmit fewer signals. Below is some information that I found at Diabetes.WebMd.com. Visit them to see the entire post titled “Diabetic Neuropathy Treatment Overview.”

People with peripheral neuropathy often have mild to severe pain in specific parts of their bodies. Talk with your doctor about treatment that can reduce your pain and improve your physical functioning, mood, and mental well-being. These treatments may include:

• Medicines such as pain relievers or creams to relieve pain. Prescription medicines often used to reduce pain from diabetic neuropathy may include medicines that are more commonly used to treat depression, such as tricyclic antidepressants and the antidepressant duloxetine hydrochloride, and medicines that control seizures, such as pregabalin and gabapentin. These medicines may be tried to reduce your pain even though you do not have depression or seizures.

• Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.

• Physical therapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy can make it hard for you to feel changes in temperature.

• Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that attempts to reduce pain by applying brief pulses of electricity to nerve endings in the skin.

In June of 2008 the Food and Drug Administration (FDA) approved duloxetine HCl delayed-release capsules (Cymbalta an SNRI) for the management of fibromyalgia. Previously, only pregabalin (Lyrica; Pfizer, Inc) was approved to treat this painful condition. Some see this as a major victory in validating fibromyalgia as a legitimate diagnosis while others see this as a greed-driven pharmaceutical ploy. Having worked with many patients who were diagnosed and living with the pain and problems of fibromyalgia I am firmly in the first camp.

Cymbalta offers relief from both the emotional and physical symptoms that are associated with depression. Cymbalta (duloxetine) is a drug that has been approved by the FDA to treat major depression as well as the pain of diabetic peripheral neuropathy (nerve damage in the hands and feet). Cymbalta, a dual reuptake inhibitor, targets two chemical messengers in the body, serotonin and norepinephrine, which play a role in both depression and pain perception.

Posted below are some research findings from studies that led to FDA approval for Cymbalta to be prescribed for fibromyalgia treatment. I found this information on Medscape which was published by News & CME Author: Yael Waknine in Medscape Medical News. If you want to see the entire report, please go to the Medscape website and search for "Cymbalta Approved for Fibromyalgia."

The [FDA] approval[for Cymbalta] was based on data from 2 pivotal double-blind, fixed-dose, randomized, phase-3 clinical trials of patients meeting the American College of Rheumatology criteria for primary fibromyalgia, including a history of widespread pain for 3 months and pain present at 11 or more of the 18 specific tender point sites. Study 1 enrolled women only (n = 354) and was 3 months in duration; study 2 enrolled both men and women (n = 520) for a period of 6 months.

Both studies compared duloxetine 60 mg or 120 mg once daily (as divided doses in study 1 and a single dose in study 2) with placebo; study 2 also evaluated the benefit of duloxetine therapy at 20 mg/day vs placebo during the initial 3 months of the 6-month study.

The mean baseline pain score was 6.5 on an 11-point Brief Pain Inventory (BPI) 24-hour average pain scale ranging from 0 (no pain) to 10 (worst possible pain); approximately 25% of participants had a comorbid diagnosis of major depressive disorder.

For the first study, results at 3 months showed that treatment with duloxetine 60 mg/day yielded clinically significant pain relief, defined as a 30% or greater reduction in BPI scores from baseline (55% vs placebo, 33%; No additional benefit was observed in patients receiving 120 mg vs 60 mg of duloxetine daily (55% vs 54%).

These findings were supported by those of the second study, which showed that duloxetine 60 and 120 mg/day was similarly effective for achieving a 30% or greater reduction in BPI scores from baseline at 3 months (50.7% and 52.1% vs placebo, 36%; P = .016 and P = .008) and for achieving a 50% or greater decrease at 6 months (32.6% and 35.9% vs 21.6%, P = .045 and P = .0009).

According to data pooled from 4 studies of fibromyalgia, the most commonly observed adverse events in duloxetine-treated patients (incidence = 5% and occurring at least twice as often vs placebo) were similar to that observed in other studies and included nausea (29% vs placebo, 11%), dry mouth (18% vs 5%), constipation (15% vs 4%), decreased appetite (11% vs 2%), somnolence (11% vs 3%), hyperhidrosis (7% vs 1%), and agitation (6% vs 2%).

Duloxetine[Cymbalta] previously was approved for the treatment of diabetic peripheral neuropathic pain, depression, and generalized anxiety disorder.

Over the past few months I’ve been hearing about more and more people being diagnosed with Central Pain Syndrome. Central Pain Syndrome is a neurological condition caused by dysfunction that specifically affects the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. It's a form of pain experienced by more than 250,000 Americans and affects more than 50 percent of spinal cord injury patients, 30 percent of multiple sclerosis patients, and 10 percent of stroke patients.

Central Pain Syndrome occurs in people who have — or who have experienced — strokes, multiple sclerosis, limb amputations, brain injuries, or spinal cord injuries. In some cases CNS didn’t develop until months or years after the injury or initial nerve damage. Central Pain Syndrome is not a fatal disorder, but the syndrome causes disabling chronic pain and suffering among the majority of individuals who have it. Central Pain Syndrome is characterized by a mixture of pain sensations, the most prominent being a constant burning. The steady burning sensation is sometimes increased by light touch. Pain also increases in the presence of temperature changes, most often cold temperatures. A loss of sensation can occur in affected areas, most prominently on distant parts of the body, such as the hands and feet. There may be brief, intolerable bursts of sharp pain on occasion.

The pain of Central Pain Syndrome can begin within days of the causative insult, or it can be delayed for years (particularly in stroke patients). While the specific symptoms of Central Pain Syndrome may vary over time, the presence of certain symptoms is essentially continuous once they begin. The pain is usually moderate to severe in nature and can be very debilitating. Symptoms may be made worse by a number of conditions, such as temperature change (especially exposure to cold), touching the painful area, movement, and emotions or stress. The pain is often difficult to describe.

Because healthcare providers cannot find a cause for the pain their patients are reporting, they are often accused of exaggerating or making up their symptoms; especially in cases where the condition doesn’t manifest for months or years after an injury or after another medical condition is resolved. Prior to being diagnosed with Central Pain Syndrome patients doubted their own reality; some contemplated or even committed suicide.

So what can be done for someone living with central pain syndrome? The main goal of treatment is to increase quality of life and provide pain relief. Unfortunately, common analgesics including opiates are usually not helpful, but are often prescribed anyway. For many people this leads to serious problems including addiction. Many sources report some of the more helpful treatment approaches that I’ve listed below:

• Tricyclic antidepressants like nortriptyline (Elavil®) are one of the most commonly prescribed drugs.

• Antidepressant medications especially Cymbalta (an SNRI) and other SNRIs and SSRIs can also be helpful.

• Anticonvulsant medication especially Gabapentin and Carbamazepine are also helpful. In addition, Lyrica (pregabalin) is often effective for neuropathic pain and is FDA approved for neuropathy and fibromyalgia and has been proven effective for spinal cord injuries. Some of the other anticonvulsant medications are: Depakote, Neurontin, Topamax, Tegretol plus several others.

• Lowering stress levels also helps to decrease the pain. Teaching patients simple relaxation response exercises and possibly biofeedback can be very helpful.

As with most chronic pain conditions it is always best to use a multidisciplinary treatment team. Neurologists will usually be the mainstay for treating central pain syndrome. Physical and occupational therapists may help an individual facing central pain syndrome obtain maximal relief and regain optimal functioning. Psychiatrists or psychotherapists may be helpful for supportive psychotherapy, particularly in patients who develop depression or other coexisting disorders related to their chronic pain.

For most people, living with chronic pain can be very difficult, especially when they also have a coexisting addiction or other psychological disorders. Given the biopsychosocial nature of chronic pain it is essential to utilize a multidisciplinary treatment plan that incorporates nonpharmacological interventions. The Addiction-Free Pain Management® (APM) System addresses the whole person with implementation of treatment plans for the biological, psychological, social, and spiritual domains.

The APM System consists of three major components: (1) A medication management plan—in consultation with an addiction medicine specialist; (2) A cognitive-behavioral treatment plan addressing pain versus suffering, treating family system issues and changing self-defeating behaviors, using eight Core Clinical Exercises from the Addiction-Free Pain Management® Workbook; and (3) A nonpharmacological pain management plan—developing safer medication-free ways to manage pain. Most pain patients need a strategic combination of all of the above.

One nonpharmacological intervention that has been successfully implemented in many treatment programs is Tai Chi which originated in China as a martial art. As a mind-body practice in complementary and alternative medicine (CAM), Tai chi is sometimes referred to as "moving meditation" where practitioners move their bodies slowly, gently, and with awareness while breathing deeply.

During my research I found several mentions of Tai Chi that I believe important to share. MedicineNet.com posted an article titled Moving Meditation: Tai Chi for Arthritis Relief. Excerpts are noted below. Please visit MedicineNet to read the entire article.

While many of today's Tai Chi movements have roots in martial arts, the goal is indeed therapeutic. Progress is measured in terms of coordination, strength, balance, flexibility, breathing, digestion, emotional balance, and a general sense of well-being.

Tai Chi and other types of mindfulness-based practices "are intended to maintain muscle tone, strength, and flexibility, and perhaps even spiritual aspects like mindfulness - focusing in the moment, focusing away from the pain," says Raymond Gaeta, MD, director of pain management services at Stanford Hospital & Clinics.

Parag Sheth, MD, assistant professor of rehabilitation medicine at Mt. Sinai Medical Center in New York, saw the popularity of Tai Chi on a visit to China 15 years ago. "We saw it every morning - thousands of people in the park doing tai chi, all of them elderly," he tells WebMD.

"There's logic in how Tai Chi works," Sheth says. "Tai Chi emphasizes rotary movements -- turning the body from side to side, working muscles that they don't use when walking, building muscle groups they are not used to using. If they have some strength in those support muscles - the rotators in the hip -- that can help prevent a fall."

"I'm an absolute huge fan of Tai Chi," says Jason Theodoskais, MD, MS, MPH, FACPM, author of The Arthritis Cure and a preventive and sports medicine specialist at the University of Arizona Medical Center. Any type of motion helps lubricate the joints by moving joint fluid, which is helpful in relieving pain, he says. "Tai Chi is not a cure-all, but it's one piece of the puzzle. What's good about Tai Chi is that it's a gentle motion, so even people who are severely affected with arthritis can do it. Also, Tai Chi helps strengthen the joints in a functional manner? You strengthen muscles in the way your body normally uses the joints."

Researchers in Australia conducted a systematic review of Tai Chi studies and found it produces positive effects in those suffering from arthritis. The researchers termed the trials small and of low methodological quality, but they found the outcomes for improvement in level of tension and for satisfaction with general health were statistically significant.

Tai Chi is a form of exercise that has recently been gaining popularity as a way to relieve and/or manage back pain and neck pain. It is often easy to associate Tai Chi with groups of people in parks or gyms moving slowly and deliberately in synchronization. These people are using the same Tai Chi principles and movements created in ancient China and still practiced all around the world as a healing exercise. Tai Chi has demonstrated usefulness in the prevention and treatment of certain problems such as back pain. Importantly, Tai Chi is non-invasive, relatively inexpensive, and gentle on the spine, so many people with back pain are starting to try it as an adjunct to (or sometimes instead of) traditional medical approaches to manage back pain. Furthermore, Tai Chi does not require any expensive equipment and can be practiced anywhere.

News & Research Archive — Here is a history of past Research for 2009, 2008 or 2007