Category: Pain Management

With Gain, No Pain: Exercise Protects against Chronic Pain

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In 2023, researchers in Norway found that among more than 10 000 adults, those who were physically active had a higher pain tolerance than those who were sedentary; and the higher the activity level, the higher the pain tolerance.

After this finding, the researchers wanted to understand how physical activity could affect the chances of experiencing chronic pain several years later. And they wondered if this was related to how physical activity affects our ability to tolerate pain.

This prompted a new study from the researchers at UiT The Arctic University of Norway, the University Hospital of North Norway (UNN), and the Norwegian Institute of Public Health, which was published in the journal PAIN.

“We found that people who were more active in their free time had a lower chance of having various types of chronic pain 7-8 years later. For example, being just a little more active, such as going from light to moderate activity, was associated with a 5% lower risk of reporting some form of chronic pain later,” says doctoral fellow Anders Årnes at UiT and UNN and study author.

He adds that for severe chronic pain in several places in the body, higher activity was associated with a 16% reduced risk.

Measured cold pain tolerance

The researchers found that the ability to tolerate pain played a role in this apparent protective effect. That explains why being active could lower the risk of having severe chronic pain, whether or not it was widespread throughout the body.

“This suggests that physical activity increases our ability to tolerate pain and may be one of the ways in which activity helps to reduce the risk of severe chronic pain,” says Årnes.

The researchers included almost 7000 people in their study, recruited from the large Tromsø survey, which has collected data on people’s health and lifestyle over decades.

After obtaining information about the participants’ exercise habits during their free time, the researchers examined how well the same people handled cold pain in a laboratory. Later, they checked whether the participants experienced pain that lasted for three months or more, including pain that was located in several parts of the body or pain that was experienced as more severe.

Among the participants, 60% reported some form of chronic pain, but only 5% had severe pain in multiple parts of the body. Few people experienced more serious pain conditions.

Pain and exercise

When it comes to exercising if you already have chronic pain, the researcher says:

“Physical activity is not dangerous in the first place, but people with chronic pain can benefit greatly from having an exercise program adapted to help them balance their effort so that it is not too much or too little. Healthcare professionals experienced in treating chronic pain conditions can often help with this. A rule of thumb is that there should be no worsening that persists over an extended period of time, but that certain reactions in the time after training can be expected.”

Source: UiT The Arctic University of Norway

Neuron Cluster may Create a Little-understood Form of Chronic Pain

Source: Pixabay CC0

Stimulating a small cluster of neurons in the brain appears to create a response in mice that mimics nociplastic pain, a type of unexplained chronic pain, researchers at the University of Washington School of Medicine in Seattle have found. 

“When we stimulate these neurons, the mouse behaves as though gentle touch is very painful, which is one of the characteristics of nociplastic pain,” said Richard Palmiter, a professor of biochemistry and investigator of the Howard Hughes Medical Institute. Dr Logan Condon, who spearheaded this research as a PhD student at UW, was lead author on the paper, which was published in Cell Reports

Chronic pain can arise from ongoing injury or persistent damage to the nervous system. Pain caused by injury is called nociceptive from the Latin nocere “to harm.” Pain due to nerve damage is called neuropathic. But these categories do not explain a common form of chronic pain the persists even after an injury has fully healed and there is no evidence of neurological damage. This led the International Association for the Study of Pain to define a new category called nociplastic pain, meaning “able to be moulded.” 

Although the cause of nociplastic pain is unknown, scientists think it involves changes in pain circuits in the spinal cord and brain. These changes result in the perception of pain even when no nerve injury exists. 

In the new study, researchers demonstrated that stimulating a cluster of cells in the brain’s parabrachial nucleus can generate chronic pain behaviour typical of nociplastic pain. They also showed that inhibiting these cells can prevent pain from nerve injury. 

The parabrachial nucleus is in an area of the brain known as the pons. It acts as a hub that relays aversive sensory information from the body to different parts of the brain. The parabrachial neurons found to create nociplastic pain are called Calca neurons, named for a defining gene for these cells. 

“You can think of these Calca neurons as a warning system for the brain,” said Palmiter. “They respond to any aversive event you can think of – a pinch, a visual threat, a bad odour, a loud noise – and they tell your brain that something bad is happening in the environment and you’d better do something about it.”

It is possible to manipulate genetically defined neurons using viral techniques to express molecules that activate, or inhibit, those neurons. 

The researchers also found that the nociplastic pain behaviour continues even after the Calca-neuron activation has stopped. This suggests signals from the stimulated Calca neurons cause persistent effects – a sign of plasticity – in the nerve circuits leading to the spinal cord. 

They also showed that it was possible to create nociplastic behaviours in the mice by exposing them to unpleasant, aversive experiences like nausea, chemotherapy drugs or migraine-like conditions. 

Palmiter’s team is currently focusing on the neural circuits and plasticity that arises when parabrachial Calca neurons are activated.

“The brain is somehow sending signals to the spinal cord,” he said. “We want to figure out the pathway for those signals.”

Source: University of Washington

Acid-lowering Meds Linked to Greater Risk of Migraines

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People who take acid-reducing drugs may have a higher risk of migraine and other severe headache than people who do not take these medications, a new study has shown. The acid-reducing drugs include proton pump inhibitors such as omeprazole and esomeprazole, histamine H2-receptor antagonists, or H2 blockers, such as cimetidine and famotidine, and antacid supplements.

The study, study published in Neurology®Clinical Practice, an official journal of the American Academy of Neurology, does not prove causation; only an association.

In acid reflux, stomach acid flows into the oesophagus, usually after a meal or when lying down, causing heartburn and ulcers. People with frequent acid reflux may develop gastroesophageal reflux disease, or GORD, which can lead to cancer of the oesophagus.

“Given the wide usage of acid-reducing drugs and these potential implications with migraine, these results warrant further investigation,” said study author Margaret Slavin, PhD, RDN, of the University of Maryland in College Park. “These drugs are often considered to be overprescribed, and new research has shown other risks tied to long-term use of proton pump inhibitors, such as an increased risk of dementia.”

For the study, researchers looked at data on 11,818 people who provided information on use of acid-reducing drugs and whether they had migraine or severe headache in the past three months.

A total of 25% of participants taking proton pump inhibitors had migraine or severe headache, compared to 19% of those who were not taking the drugs. A total of 25% of those taking H2 blockers had severe headache, compared to 20% of those who were not taking those drugs. And 22% of those taking antacid supplements had severe headache, compared to 20% of those not taking antacids.

When researchers adjusted for other factors that could affect the risk of migraine, such as age, sex and use of caffeine and alcohol, they found that people taking proton pump inhibitors were 70% more likely to have migraine than people not taking proton pump inhibitors. Those taking H2 blockers were 40% more likely and those taking antacid supplements were 30% more likely.

“It’s important to note that many people do need acid-reducing medications to manage acid reflux or other conditions, and people with migraine or severe headache who are taking these drugs or supplements should talk with their doctors about whether they should continue,” Slavin said.

Slavin noted that the study looked only at prescription drugs. Some of the drugs became available for over-the-counter use at non-prescription strength during the study period, but use of these over-the-counter drugs was not included in this study.

Other studies have shown that people with gastrointestinal conditions may be more likely to have migraine, but Slavin said that relationship is not likely to fully explain the tie between acid-reducing drugs and migraine found in the study.

A limitation of the study is that a small number of people were taking the drugs, especially the H2 blockers.

Source: American Academy of Neurology

A Third of Women Experience Migraines Associated with Menstruation

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Of the nearly 20 million women who participated in a U.S. national health survey, one-third reported migraines during menstruation. The analysis was conducted by researchers at Georgetown University Medical Center and Pfizer, Inc., which makes a migraine medication.

Because of the underuse of medications to help treat or prevent menstrual migraines, investigators wanted to understand how common menstrual migraines were and which groups of women could most benefit from potential therapies. The study, presented April 16, at the American Academy of Neurology 2024 Annual Meeting in Denver, also revealed the most common medications taken by those women seeking to prevent menstrual migraines.

“The first step in helping a woman with menstrual migraine is making a diagnosis; the second part is prescribing a treatment; and the third part is finding treatments patients are satisfied with and remain on to reduce disability and improve quality of life,” says the study author, Jessica Ailani, MD, professor of clinical neurology at Georgetown University School of Medicine.

The researchers used the 2021 U.S. National Health and Wellness Survey to analyse responses from women who reported their current migraine treatments, frequency and disabilities via the Migraine Disability Assessment Test (MIDAS), a five-question survey. A migraine headache can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

“Discrepancies in the incidence of who gets migraine attacks associated with menses is likely due to premenopausal women having more regular menstrual cycles and thus more menstrual-related migraines,” says Ailani, also director of the MedStar Georgetown Headache Center at Medstar Georgetown University Hospital. “Additionally, as women move into their 40’s and become peri-menopausal, there tends to be a greater shift through the month in hormone levels also leading to frequent migraine attacks.”

The survey found that for all women during their menstrual periods, migraine attacks occurred as frequently as 4.5 times and that monthly only migraine headaches lasted 8.4 days, on average; 56.2 % of women had moderate-to-severe migraine-specific disabilities that ranked highest on the MIDAS scale.

When looking at treatments women in the survey used to help control their migraine symptoms, 42.4% used over-the-counter medications while 48.6% used prescription medications. Of the 63.9 % of women who used migraine treatments for acute symptoms, the most commonly used were triptans, a class of drugs developed in the 1990s to quiet overactive nerves associated with migraines and cluster headaches.

Sara’s story

Sara, a 38 year old mother of two, says her migraines are predictably and consistently worse during her period.

“It definitely disrupts my ability to go about my normal activities including at work,” Sara says. “I’m pretty lucky that I’m generally responsive to prescription medication, but I often still have to lie down for an hour or so while the medicine kicks in.”

Sara is being treated preventatively for migraines with Botox. She says over the past couple of months, she’s had a couple of migraines outside of when she gets her period, but that the headaches are definitely worse during menstruation.

“While I had my last period, I had a migraine every day for a week,” Sara says. “It’s starkly different [during menstruation].”

Prevention possibilities

Non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes used as preventive medications for women with regular menstrual periods. In this study, 21.1% of women reported use of any migraine prevention medications or therapies.

“Preventive treatments are used less frequently than acute treatment for migraine,” Alaini said. “In my opinion, this is because preventive therapy is a long-term commitment by both a woman and her clinician to improving the disease process. Migraine is a life-long brain disease without a cure, and the goal of preventive therapy is to reduce disease burden and improve quality of life. Unfortunately, newer disease-specific treatments are costly, so generic older treatments are often used and come with greater side effects.”

Next steps

The researcher’s next steps involve looking at larger databases to see if they can mimic findings on a global scale. They want to determine if women with menstrual-related migraine are frequently turning to non-migraine treatments as was seen in around 53% of their current study group.

“As a headache specialist in the U.S., I know I can do better for women in my clinic, but what can be done for the millions of women who don’t get into a headache clinic? That is our true next step,” says Ailani. “If you have migraines related to your menstrual cycle, discuss this with your gynaecologist or neurologist. There are treatments that can help and if the first treatment tried does not work, do not give up.”

Source: Georgetown University Medical Center

Virtual Reality Sessions can Lessen Cancer Pain, Trial Shows

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Hospitalised cancer patients who engaged in a 10-minute virtual reality (VR) session experienced significantly lessened pain in a trial published in CANCER, a peer-reviewed journal of the American Cancer Society. Participants still experienced sustained benefits a day later.

Most cancer patients experience pain, and treatment usually involves medications including opioids. VR sessions that immerse the user in new environments have been shown to be a noninvasive and nonpharmacologic way to lessen pain in different patient populations, but data are lacking in individuals with cancer. To investigate, Hunter Groninger, MD, of Georgetown University School of Medicine and MedStar Health and his colleagues randomized 128 adults with cancer with moderate or severe pain to a 10-minute immersive VR intervention involving calm, pleasant environments or to a 10-minute two-dimensional guided imagery experience on an iPad tablet.

The investigators found that both interventions lessened pain, but VR sessions had a greater impact. Based on patient-reported scores from 0 to 10, patients in the guided imagery group reported an average decrease of 0.7 in pain scores, whereas those in the VR group reported an average drop of 1.4. Twenty four hours after the assigned intervention, participants in the VR group reported sustained improvement in pain severity (1.7 points lower than baseline before the VR intervention) compared with participants in the guided imagery group (only 0.3 points lower than baseline before the active control intervention).

Participants assigned to the VR intervention also reported improvements related to pain “bothersomeness” (how much the pain bothered them, regardless of the severity of the pain) and general distress, and they expressed satisfaction with the intervention. 

“Results from this trial suggest that immersive VR may be a useful non-medication strategy to improve the cancer pain experience,” said Dr Groninger. “While this study was conducted among hospitalized patients, future studies should also evaluate VR pain therapies in outpatient settings and explore the impact of different VR content to improve different types of cancer-related pain in different patient populations. Perhaps one day, patients living with cancer pain will be prescribed a VR therapy to use at home to improve their pain experience, in addition to usual cancer pain management strategies like pain medications.”

Source: Wiley

Earlier Retirement for People with Chronic Musculoskeletal Pain

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Frequent musculoskeletal pain is linked with an increased risk of exiting work and retiring earlier, according to a new study published this week in the open-access journal PLOS ONE by Nils Niederstrasser of the University of Portsmouth, UK, and colleagues.

Previous studies have shown higher rates of absenteeism, reduced working capacity and reduced income for people with chronic musculoskeletal pain. The prevalence of people living with musculoskeletal pain increases with age, but few studies have specifically focused on the effects of chronic pain on the employment status of older populations.

In the new study, Niederstrasser and colleagues used data on 1156 individuals aged 50+ living in England and taking part in the English Longitudinal Study of Ageing. Over the course of the 14-year data collection period, 1073 of the individuals retired.

The researchers found that people with more musculoskeletal pain complaints tended to retire earlier compared to pain-free participants (HR = 1.30, CI = 1.12–1.49). Participants suffering from musculoskeletal pain were also 1.25 times more likely to cease work sooner (CI = 1.10–1.43), whether or not they described themselves as retired. Other factors associated with earlier retirement age included higher work dissatisfaction and higher self-perceived social status. Frequent musculoskeletal pain remained a significant predictor of earlier retirement and risk of work cessation at earlier ages even when controlling for the influence of job satisfaction, depressive symptoms, self-perceived social status, sex, and working conditions.

The authors conclude that pain experiences can lead to poor work outcomes and point out that further research should establish the mechanisms and decision making involved in leaving the workforce for people with frequent musculoskeletal pain.  

The authors add: “It is remarkable that pain predicts earlier retirement and work cessation to a similar extent or even more strongly than other variables, such as job satisfaction or specific job demands. It shows just how much impact pain can have on all aspects of people’s lives.”

Astronauts’ ‘Space Headaches’ may Yield Insights into Those Suffered on Earth

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Space travel and zero gravity can take a toll on the body. A new study has found that astronauts with no prior history of headaches may experience migraine and tension-type headaches during long-haul space flight, which includes more than 10 days in space. Studying this type of headache may provide new insights into the mechanisms behind headaches on Earth. The study was published in Neurology.

“Changes in gravity caused by space flight affect the function of many parts of the body, including the brain,” said study author W. P. J. van Oosterhout, MD, PhD, of Leiden University Medical Center in the Netherlands.

“The vestibular system, which affects balance and posture, has to adapt to the conflict between the signals it is expecting to receive and the actual signals it receives in the absence of normal gravity. This can lead to space motion sickness in the first week, of which headache is the most frequently reported symptom. Our study shows that headaches also occur later in space flight and could be related to an increase in pressure within the skull.”

The study involved 24 astronauts from the European Space Agency, the U.S. National Aeronautics and Space Administration (NASA) and the Japan Aerospace Exploration Agency. They were assigned to International Space Station expeditions for up to 26 weeks from November 2011 to June 2018.

Prior to the study, nine astronauts reported never having any headaches and three had a headache that interfered with daily activities in the last year.

None of them had a history of recurrent headaches or had ever been diagnosed with migraine.

Of the total participants, 22 astronauts experienced one or more episode of headache during a total of 3596 days in space for all participants. Astronauts completed health screenings and a questionnaire about their headache history before the flight.

During space flight, astronauts filled out a daily questionnaire for the first seven days and a weekly questionnaire each following week throughout their stay in the space station.

The astronauts reported 378 headaches in flight. Researchers found that 92% of astronauts experienced headaches during flight compared to just 38% of them experiencing headaches prior to flight.

Of the total headaches, 170, or 90%, were tension-type headache and 19, or 10%, were migraine. Researchers also found that headaches were of a higher intensity and more likely to be migraine-like during the first week of space flight.

During this time, 21 astronauts had one or more headaches for a total of 51 headaches – of which 39 were considered tension-type headaches and 12 were migraine-like or probable migraine.

In the three months after return to Earth, none of the astronauts reported any headaches.

“Further research is needed to unravel the underlying causes of space headache and explore how such discoveries may provide insights into headaches occurring on Earth,” said Van Oosterhout.

“Also, more effective therapies need to be developed to combat space headaches as for many astronauts this a major problem during space flights.”

This research does not prove that going into space causes headaches; it only shows an association.

A limitation of the study was that astronauts reported their own symptoms, so they may not have remembered all the information accurately.

Source: American Academy of Neurology

Can Yoga Effectively Treat Chronic Back Pain?

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New research published in the Journal of Orthopaedic Research suggests that the physical postures, breathing exercises, and mindfulness practices of yoga may benefit individuals with back pain.

In the study, 10 women with and 11 without chronic low back pain underwent an 8‐session yoga program over 4 weeks, with the first session conducted in a clinic and the rest delivered with a tele‐approach. Women with chronic low back pain experienced a significant decrease in pain intensity, as assessed through a 10-point visual analogue scale (an average pain of 6.80 at the start, dropped to 3.30 after the sessions) and through a spine-related measure called the flexion–relaxation phenomenon, which is often absent or disrupted in people with low back pain  (5.12 at the start versus 9.49 after the sessions).

The findings suggest yoga can positively impact the neuromuscular response during trunk flexion and pain perception in individuals with chronic low back pain.

“It was interesting to show the role that yoga might play in the management of chronic back pain,” said corresponding author Prof Alessandro de Sire, MD, of the University of Catanzaro “Magna Graecia” and University Hospital “Renato Dulbecco,” in Italy.

The authors noted that further research is warranted to assess yoga’s long‐term effects.

Source: Wiley

For Neuropathic Pain, the More Capsaicin Patch Applications the Better

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Capsaicin, derived from hot chili pepper plants, has been used to treat various types of pain, and a high concentration capsaicin patch (HCCP) is approved for the treatment of neuropathic pain. In a real-world study published in Pain Practice that included 97 outpatients in Germany diagnosed primarily with neuropathic back pain, postoperative/posttraumatic neuropathic pain, or postherpetic neuralgia (shingles pain), patients appeared to benefit from multiple HCCP applications.

Among the study participants, 38 received 2 HCCP treatments, and 59 received at least 3. Following HCCP treatments, most patients required significantly lower doses of opioids to manage their pain. Also, two-thirds of patients experienced a reduction in pain intensity after multiple HCCP treatments, and the proportion of patients experiencing a reduction in pain intensity was substantially higher among those who received at least 3 applications compared with those who received 2 applications.

“Consistent with the progressive response seen in prospective clinical trials involving repeated use of topical capsaicin, our research indicates that patients appear to benefit from multiple applications in terms of pain intensity and concomitant opioid use in real-world clinical practice,” said corresponding author Kai-Uwe Kern, MD, PhD, of the Institute for Pain Medicine/Pain Practice, in Wiesbaden, Germany.

Source: Wiley

Among Cancer Survivors, Physical Activity is Linked to Reduced Pain

Study shows that higher levels of physical activity are linked with less pain, and to a similar extent in adults with and without a history of cancer.

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People who have had cancer often experience ongoing pain, but a new study reveals that being physically active may help lessen its intensity. The study is published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.

Although physical activity has been shown to lessen various types of pain, its effects on cancer-related pain are unclear. To investigate, a team led by senior author Erika Rees-Punia, PhD, MPH, of the American Cancer Society, and first author Christopher T.V. Swain, PhD, of the University of Melbourne, in Australia, analysed information pertaining to 51 439 adults without a history of cancer and 10,651 adults with a past cancer diagnosis. Participants were asked, “How would you rate your pain on average,” with responses ranging from 0 (no pain) to 10 (worst pain imaginable). Participants were also asked about their usual physical activity.

US guidelines recommend 150 minutes (2 hours 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity, or 75 minutes (1 hour 15 minutes) to 150 minutes (2 hours 30 minutes) a week of vigorous-intensity aerobic physical activity.

Based on participants’ responses, the investigators found that, for individuals who had cancer in the past as well as for those without a history of cancer, more physical activity was linked with lower pain intensity. The extent of the association was similar for both groups of individuals, indicating that exercise may reduce cancer-related pain just as it does for other types of pain that have been studied in the past.

Among participants with a past cancer diagnosis, those exceeding physical activity guidelines were 16% less likely to report moderate-to-severe pain compared to those who failed to meet physical activity guidelines. Also, compared with people who remained inactive, those who were consistently active or became active in older adulthood reported less pain.

“It may feel counterintuitive to some, but physical activity is an effective, non-pharmacologic option for reducing many types of pain. As our study suggests, this may include pain associated with cancer and its treatments,” said Dr Rees-Punia. 

Source: Wiley