Category: Pain Management

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TENS Shown to Improve Pain and Fatigue in Fibromyalgia

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Real-world trial finds long-lasting benefit for TENS with physical therapy in reducing movement pain, fatigue

Credit: University of Iowa

Adding TENS (transcutaneous electrical nerve stimulation) to outpatient physical therapy reduced movement-based pain and fatigue in patients with fibromyalgia, and the effects lasted for at least six months, according to a new study led by researchers at University of Iowa Health Care.  

The study, led by Kathleen Sluka, PT, PhD, is the first real-world trial of TENS for fibromyalgia. The findings, published on March 27 in the journal JAMA Network Open, show that TENS is a safe, effective, inexpensive, and readily available treatment for fibromyalgia, a chronic condition that causes pain, tenderness, and fatigue throughout the body. 

“It is one of the few treatments that specifically targets movement-evoked pain and fatigue, which are major barriers to participation in daily activities,” says Sluka, UI professor of physical therapy and rehabilitation science. 

TENS uses a small device with adhesive electrodes to send mild electrical pulses through the skin to block or reduce pain. The study found that the effect of TENS for reducing pain was similar, if not better, than current FDA-approved medications for fibromyalgia. 

“We were excited to see that patients also had less fatigue,” Sluka added. “Right now, there are no good treatments for fatigue. So, the fact that we had anything that touched the fatigue was pretty powerful.”

Fibromyalgia: complicated, misunderstood, and hard to treat 

Fibromyalgia affects about 4% to 7% of the population. It significantly impacts a person’s physical function, cognitive abilities, and sleep. In addition to chronic pain, a key feature of the condition is whole-body fatigue, which interferes with day-to-day life and contributes to patients’ inability to concentrate and perform functional activities. 

Exercise is often the first line of treatment recommended to people with fibromyalgia, and research has shown that it can be beneficial. However, fibromyalgia causes fatigue and pain, which is a key reason why the research team focused on alleviating pain with movement. 

“Pain with movement hinders a person’s ability to participate in an effective exercise program and do their day-to-day activities.” Sluka says.  

Science translated to real-world benefit 

Sluka and her colleagues have spent decades studying the biological mechanisms affected by TENS, developing the ideal parameters of TENS stimulation and testing the efficacy of TENS for treating chronic pain and fatigue in human trials. 

They have previously shown that under the ideal conditions of a randomized, controlled clinical trial, TENS in conjunction with physical therapy can significantly decrease movement pain. 

The new Fibromyalgia TENS in Physical Therapy (FM-TIPS) study was designed to test the effect of TENS under real-world conditions. The study was conducted in 28 outpatient physical therapy clinics across six health care systems in the Midwest, and included 384 people of different ages, education levels, and socioeconomic backgrounds. Almost 50% of the participants were from rural areas.  

“It was a challenge to recruit participants for this study, but the clinics and the physical therapists we worked with were great. This would never have happened without them,” Sluka says.

The clinics were randomised to provide either physical therapy (PT) with TENS or physical therapy alone. In the PT-TENS group, participants were asked to use TENS for two hours a day for six months. That time could be split into short periods or done all at once. The TENS electrodes were placed on the upper and lower back and delivered a mixed frequency signal at an intensity as strong as the participant could tolerate. 

After 60 days, movement-evoked pain during TENS treatment was significantly improved in the PT-TENS group. Adding TENS also significantly reduced resting pain and resting and movement-fatigue. In contrast, participants who received only physical therapy had no change in their movement-evoked pain. 

When we gave the PT-only patients the TENS unit and they started using it, we also saw the same improvements as the PT with TENS patients, which is powerful. – Kathleen Sluka, PT, PhD

The response also was dose-dependent, with people who used TENS daily for 60 days having the best outcomes. 

Unlike many pain-relieving drugs that can become less effective over time as the body develops a tolerance for the medication, the study shows that over time, TENS maintained its ability to improve pain and fatigue at a significant level. 

After the primary endpoint at day 60, the PT-only group was also given TENS, and all the participants continued in the study for another four months. 

“When we gave the PT-only patients the TENS unit and they started using it, we also saw the same improvements as the PT with TENS patients, which is powerful,” Sluka says. 

Overall, the study showed that 80% of patients found TENS helpful. At six months, 80% were still using TENS once a week, and over 70% reported they felt better after using TENS. 

TENS adds benefit

Dana Dailey, PT, PhD, UI assistant research scientist and the first author of the study, notes that it’s important for people to realize that the benefit of TENS comes from using it as a part of a total treatment plan that includes physical therapy.  

“Using TENS on its own will not give the same benefits,” Dailey says. “However, the study shows that TENS provides an added benefit on top of any relief from other treatments. All the study participants were also using pain medications and receiving physical therapy, yet TENS still provided additional relief.” 

Fibromyalgia often needs multiple interventions to help patients feel less pain and fatigue and improve their overall function. The new findings suggest that TENS could be particularly helpful as a part of a multipronged approach because it can be safely and easily used as a self-management tool that uniquely targets movement-associated pain and fatigue. 

“Often, when you move a randomised, controlled clinical trial into a real-world setting, it doesn’t work because there are too many confounding factors. But this intervention still works,” Sluka says. “Not only did the treatment reduce movement pain and fatigue during the testing period, but patients continued to use it at six months.” 

By Jennifer Brown

Source: University of Iowa

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Pain Neurons Protect Nerve Health and Offer New Therapeutic Targets

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A healthy neuron. Credit: NIH

Researchers at Karolinska Institutet, have uncovered a previously unknown mechanism that helps pain sensing nerve cells stay healthy and respond to injury. The findings, published in Nature Communications, may improve understanding of chronic pain and nerve damage and maintenance of myelin integrity.

A new study shows that a molecule called RNase4, is produced by specialised pain-sensing neurons. It plays a key role in maintaining their normal function and influences both these neurons and the structure of nearby nerve fibres, positioning pain-sensing neurons not only as sensory transducers but also as sentinels of nerve integrity.

The researchers showed that RNase4 is expressed in unmyelinated sensory neurons, including neurons that innervate the auditory organ, and in the pain-sensing neurons that innervate the face, head, dura mater, and the rest of the body. By combining multiple experimental approaches on mice, they demonstrated that loss of RNase4 alters mechanical pain responses and disrupts the myelin structure surrounding neighbouring nerve fibres. They also found that RNase4 levels increase after nerve injury, both during the pain phase and the subsequent recovery period.

“Our results point to RNase4 as part of a regulatory pathway that supports nerve integrity. This molecule has not previously been linked to pain sensing neurons, so its presence and role came as a surprise,” says corresponding author Saida Hadjab, head of the Neurobiology of pain & Therapeutics laboratory at the Department of Neuroscience.

Chronic pain is often difficult to treat, partly because the underlying biology is still not fully understood. The findings suggest that pain sensing neurons may take on a more active role in maintaining the health of surrounding nerve tissue.

“This work has enabled us to identify a novel mechanism and position RNase4 as a regulator of afferent neuron integrity and local microenvironment. The localisation of RNase4 and its function in sensory neurons made it directly relevant to hearing dysfunction, headache, and chronic pain,” says Saida Hadjab.

RNase4 shows a comparable expression pattern in human pain-sensing neurons, supporting its potential relevance in humans. While further research is required to develop therapies targeting the RNase4 pathway, these findings provide a strong foundation for advancing the study of myelin integrity and long-lasting pain in humans.

Source: Karolinska Institutet

Categories : Paediatrics Pain ManagementTags :

Sugar Comforts Newborn Babies During Painful Procedures

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Researchers have found that sucrose can relieve newborn babies’ pain during common hospital procedures

Photo by Christian Bowen on Unsplash

A new Cochrane review has found that sucrose can help with pain relief in newborn babies during common hospital procedures, such as venepuncture. This involves drawing blood with a needle, typically for testing. 

Newborns, especially preterm infants in neonatal intensive care units (NICUs), undergo numerous painful procedures. Because of their immature pain regulation, they can experience these procedures intensely. Preventing and treating procedural pain in hospitalized newborns is important, as repeated untreated pain has been associated with poorer physical growth and potential effects on brain development.

Accessible, low-cost solutions such as sucrose – a sweet sugar solution placed in a baby’s mouth shortly before needle procedures – have been used for decades. However, evidence specific to some procedures, such as venepuncture, has been limited.

Despite sucrose being recommended in multiple guidelines for procedural pain relief in infants, its use in clinical settings remains inconsistent.

Low-cost, safe intervention

The new review examined 29 clinical trials involving more than 2700 preterm and full-term babies undergoing venepuncture in hospital. It found that sucrose probably reduces pain during and immediately after the needle procedure when compared to no treatment, water or standard care. The findings also suggest that sucrose works especially well when combined with non-nutritive sucking, such as a pacifier or dummy. 
 

“Newborn babies undergo frequent needle procedures in hospital without any pain relief or comforting measures, even though older children and adults rarely have these procedures done without pain care.

The evidence shows that a small amount of sucrose given just before the procedure is a simple, fast and effective way to reduce that pain. Our review helps clinicians use this evidence more confidently and consistently in practice.”

— Mariana Bueno, University of Toronto


None of the studies included in the review reported immediate side effects from sucrose when used in the small amounts required for pain relief. However, the studies focused on short-term effects, and more research is needed to understand any potential long-term effects of repeated use in babies who spend extended time in neonatal care.
 

“Parents may be surprised to learn that something as simple as a few drops of sugar solution can make a real difference to their baby’s comfort during blood tests. 

This is a low-cost, safe intervention that works within minutes, and it can be especially helpful when other comforting methods like skin-to-skin contact or breastfeeding aren’t possible.”

— Ligyana Candido, University of Ottawa

Treated like other medications

Although sucrose is already widely used in neonatal units, the researchers found considerable variation in how it is given, including differences in dose and timing. 

Bueno added:
 

“What stood out to me when doing this review was the wide variation in how sucrose was given to newborns.”


The authors suggest the findings can help inform clearer clinical protocols and more consistent practice.

They also highlight that sucrose should be used purposefully for painful procedures and documented appropriately, rather than being given routinely to settle a crying baby. 


“To ensure safety and clinical consistency, sucrose must be administered under formal medication protocols that define specific timing and dosage for painful procedures.”

— Jiale Hu, Virginia Commonwealth University


The review authors say future research should focus on comparing effective comfort measures such as skin-to-skin contact, breastfeeding and sucrose with each other, rather than continuing to compare them to no treatment, and on understanding any potential long-term effects of repeated use in babies who spend extended time in neonatal care. 

By Mia Parkinson

Read the review

Source: Cochrane

Categories : Pain ManagementTags :

Why is Migraine More Common in Women than Men?

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Photo by Andrea Piacquadio

Lakshini Gunasekera, Monash University; Caroline Gurvich, Monash University; Eveline Mu, Monash University, and Jayashri Kulkarni, Monash University

We’ve known for a long time that women are more likely than men to have migraine attacks.

As children, girls and boys experience migraine equally. But after puberty, women are two to three times more likely to experience this potentially debilitating condition.

Recently, an Australian study showed it may be even more common than we previously thought – as many as one in three women live with migraine.

For comparison, migraine affects roughly one in 15 men in Australia.

So, what’s behind the difference? Here’s what we know.

More than a headache

Migraine is not just a bad headache – it is a complex disorder that causes the brain to process sensory information abnormally.

This means “migraine brains” can have difficulty processing information from any of the five senses:

  • sight (leading to problems with light sensitivity and glare)
  • sound (leading to noise sensitivity)
  • smell (certain smells can trigger headaches)
  • touch (leading to face or scalp tenderness)
  • taste (causing distorted taste, nausea and vomiting).

Migraine attacks typically last anywhere from four hours to three days – but can be longer.

In addition to the symptoms above, attacks can include throbbing head pain, dizziness, fatigue and difficulty concentrating. It is these extra symptoms that help diagnose migraine – not the location of head pain or pain severity.

Why are attacks more frequent in women?

Puberty is when the difference between men and women emerges. This is when our bodies massively increase the production of sex hormones.

People are often surprised to learn that both men and women produce oestrogen, progesterone and testosterone. Testosterone levels are higher in men, whereas women have higher levels of oestrogen and progesterone.

However, it is not just the type of hormone that makes a difference, but the way they fluctuate over time.

For many women, there are certain “milestone moments” when their migraine tends to worsen due to hormonal fluctuations – puberty, menstruation, pregnancy and perimenopause (the lead-up to your final period).

For example, some women notice migraine flare-ups every month, linked to phases in their monthly menstrual cycle when oestrogen levels drop.

They might even be able to predict when their period will start, as migraine attacks typically start a few days before the bleeding.

How hormones affect the brain

Women with migraine can be more sensitive to hormonal changes. This is particularly the case for sudden decreases in oestrogen. But even more subtle changes to hormone levels can cause migraine attacks.

These hormonal changes can activate brain processes that trigger migraine, such as cortical spreading depression. This is a very slow wave of electrical activity that spreads in the brain, causing some areas to function more slowly than others after it passes.

Decrease in oestrogen can also affect how we receive and process information through the trigeminal nerve. This plays a key role in the onset and maintenance of migraine pain.

Diagram showing the trigeminal nerve in the head.
Oestrogen can affect how we process information through the trigeminal nerve. ttsz/Getty

All kinds of fluctuations can be a trigger

Pregnancy can often destabilise migraine again and make attacks more likely, even when someone has previously enjoyed a period of good migraine control.

Migraine symptoms often become uncontrolled in the first trimester in particular, due to rapid hormonal changes needed to sustain a pregnancy. This usually settles in the second and third trimesters, when hormonal changes stabilise.

However, giving birth is yet another change.

Towards the end of pregnancy, oestrogen levels can be 30 times higher than pre-pregnancy levels, and progesterone can be 20 times higher. When these hormones plummet back to normal after giving birth, migraine attacks can often sharply worsen again.

Perimenopause can also involve random surges of oestrogen from the dwindling supplies of eggs within the ovaries – which previously produced these hormones cyclically and in abundance. This irregular hormone production can cause random spikes in migraine attacks. It can be extra challenging when combined with other symptoms of menopause such as hot flushes or mood changes.

Hormonal contraceptives and menopause hormone therapy can also affect migraine control. Sometimes, supplementing hormones at a regular, steady daily dose can help manage the hormone-sensitive headaches and other symptoms. However, for others, adding extra hormones can cause head pain to flare up.

Does migraine run in the family?

Genes also play a role. It’s not a coincidence that migraine is passed down in families through the maternal side.

This is because mothers pass on mitochondria to children (while fathers do not). Mitochondria are parts inside the cell that control energy.

People with migraine have fewer functional enzymes within their mitochondria, meaning their brains are in an energy-deficient state. This worsens with migraine attacks as there is even more stress to the system.

This is also why extra stress (such as sleep deprivation, missed meals, or emotional stress) can trigger a migraine and worsen pain.

There is also a strong link between migraine in women and anxiety and depression – conditions women are more likely to develop in response to stressful life events.

Knowing your own patterns

If you suspect hormones may be affecting your migraine attacks, it is helpful to keep a diary of symptoms, including headaches. Mark each day per month where you get migraine symptoms, as well as your period, to find patterns.

Identifying patterns in pain flares helps doctors guide you to a personalised medication plan, which may include hormone therapies or non-hormonal therapies.

Lakshini Gunasekera, PhD Candidate in Neurology, Monash University; Caroline Gurvich, Associate Professor and Clinical Neuropsychologist, Monash University; Eveline Mu, Research Fellow in Women’s Mental Health, Monash University, and Jayashri Kulkarni, Professor of Psychiatry, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Categories : Pain ManagementTags :

Scientists Find Hidden Trigger Behind Achilles Pain and Tennis Elbow

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Achilles tendon injury. Credit: Scientific Animations CC0

Complaints such as pain in the Achilles tendon, tennis elbow, swimmer’s shoulder and jumper’s knee are familiar to many young sportspeople, as well as to older individuals. These conditions are all caused by overloading of tendons and are generally very painful.

“Tendons are fundamentally susceptible to overuse,” explains Jess Snedeker, a professor of orthopaedic biomechanics at ETH Zurich and Balgrist University Hospital in Zurich. “They must withstand powerful loads, with all the forces of our muscles being concentrated to the relatively thin tendons that transmit these forces into movement of our skeleton.”

In medical terms, the aforementioned conditions are known as tendinopathies. They are some of the most frequent conditions seen by orthopaedic specialists, but treatment options are extremely limited. Although physiotherapy can help, there are many serious cases for which this treatment does not achieve much. Scientists are therefore keen to research these tendon problems in greater depth with a view to developing effective treatments.

Not just correlation – causation

Now, a team of researchers led by Snedeker and by Katrien De Bock, professor of exercise and health at ETH Zurich, has reached a new milestone. In the HIF1 protein, they have identified a central molecular driver of tendon problems of this kind. A part of HIF1 acts as a transcription factor, which controls the activity of genes in cells.

This protein was already known to be present at elevated levels in diseased tendons. However, it was unclear whether the increase was simply a concomitant phenomenon or whether the conditions are actually triggered by the protein. In experiments in mice and with tendon tissue from humans, the team of researchers has now shown the latter to be the case.

Treatment before it is too late

In mouse experiments, the researchers either activated the HIF1 protein permanently or switched it off completely. Whereas they observed tendon disease even without overloading in the mice with permanently activated HIF1, no tendon disease occurred in the mice if HIF1 was deactivated in tendons, even in the case of overloading.

Both in the mice and in the experiments with human tendon cells, which the researchers obtained from tendon surgeries at the hospital, they were able to show that elevated HIF1 levels in the tissue leads to a pathogenic remodelling of the tendons: More crosslinks form within the collagen fibres that make up the basic structure of the tendons.

“This makes the tendons more brittle and impairs their mechanical function,” explains Greta Moschini, a doctoral student in De Bock and Snedeker’s groups and lead author of the study. In addition, blood vessels and nerves growth into the tendon tissue. “This could be the explanation for the pain commonly observed in tendinopathy,” says Moschini.

“Our study not only provides new insight into how the disease develops. It also shows that it’s important to treat tendon problems early,” says Snedeker. He is thinking particularly of young athletes, who frequently struggle with tendinopathies. In these cases, it is often still possible to treat the problems. “However, the damage caused by HIF1 in tendon tissue can accumulate and become irreversible over time. Physiotherapy then no longer helps, and the only treatment at this moment is to surgically remove the diseased tendon.”

A starting point to search for treatments

The fact that HIF1 has now been identified as a molecular driver raises the question whether it is possible to develop medicines that deactivate HIF1 and therefore can prevent or cure tendon disease. It is not quite that easy, explains ETH Professor De Bock. In many organs of the body, HIF1 is responsible for detecting hypoxia and activating a physiological adaptation. “Switching HIF1 off throughout the body would likely lead to side effects,” she says.

It may be possible to look for methods that specifically deactivate HIF1 only in the tendon tissue. In De Bock’s view, however, the more promising approach would be to explore the biochemical processes around HIF1 in the cells in greater detail. This could help to identify other molecules that are influenced or controlled by HIF1 and that could be more suitable targets for the treatment of tendinopathy. The researchers will now embark on precisely that search.

Source: ETH Zurich

Categories : Mental Health Pain ManagementTags :

Pain in Teens Linked to Increased Risk of Self-harm

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Photo by Inzmam Khan

Adolescents who report pain at the age of 18 are at higher risk of later self-harm. This is shown by a new study from Karolinska Institutet, published in Psychiatry Research. The findings suggest that pain may form part of the chain of events leading to self-harming behaviour.

A new study from Karolinska Institutet has examined the association between pain symptoms and self-harm during childhood and adolescence. The researchers followed 16 948 twin pairs born in Sweden between 1992 and 2010. Participants reported pain at the ages of 9 and 18 and were subsequently followed through national registers until a maximum age of 24.

The aim was to investigate how genetic and environmental factors influence both pain and self-harm, as well as how the associations between pain and self-harming behaviour develop over time. Using so-called twin models, the researchers were able to estimate how much of the variation could be explained by heredity, shared environment or individual experiences.

“We see that both genetic factors and individual environmental factors play a role in both pain and self-harm in childhood as well as adolescence,” says Jenny Rickardsson, researcher at the Department of Clinical Neuroscience, Karolinska Institutet.

The results also show that pain before and up to the age of 18 was associated with a higher likelihood of later self-harm. Adolescents with pain symptoms had approximately a 60 per cent higher risk of self-harm compared with peers without pain. The association could not be explained by factors such as family environment or genetic similarity between twins.

“Our analyses suggest that pain may partly lie within the causal pathway leading to self-harming behaviour, and that the association is not solely due to familial factors,” says Jenny Rickardsson.

The study further shows that the shared family environment had little impact on either pain or self-harm, while genetic factors and individual experiences accounted for a larger proportion of the variation.

The study is based on data from the Swedish Twin Registry and was funded by Fonden för Psykisk Hälsa and Hjärnfonden. The researchers report no conflicts of interest that may have influenced the results.

Source: Karolinska Institutet

Categories : Pain ManagementTags :

No Evidence that Cannabis Meds Relieve Chronic Neuropathic Pain

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A new Cochrane review has found no clear evidence for cannabis-based medicines work for chronic neuropathic pain

Photo by Kindel Media on Unsplash

There is no clear evidence that cannabis-based medicines provide pain relief for chronic neuropathic pain, an updated Cochrane review finds.

Chronic neuropathic pain is caused by nerve damage. Existing medications help only a minority of patients, driving interest in alternatives, such as cannabis-based medicines. These can include herbal cannabis or isolated ingredients of the cannabis plant such as tetrahydrocannabinol (THC) by inhalation, mouth sprays, tablets, creams, and patches placed on the skin.

Researchers reviewed 21 clinical trials involving more than 2100 adults, comparing cannabis-based medicines with placebo over periods of two to 26 weeks. 

Cannabis-based medicines were grouped into three types: products which contain mostly THC, the psychoactive component of cannabis; products which contain mostly cannabidiol (CBD), a non-intoxicating compound; and balanced THC/CBD products, which contain similar amounts of both. 

The review found no high-quality evidence that cannabis-based medicines reduce neuropathic pain more than placebo across the three types of medicines. While some small improvements were reported by patients using products with both THC and CBD, these changes were not large enough to be considered clinically meaningful. 

Reporting of adverse events was not consistent across the included trials, so certainty around side-effects was low to very low across all types of cannabis-based medicines. Products containing THC were associated with increases in symptoms such as dizziness and drowsiness, with a potential increase in the number of people withdrawing from trials due to side effects. 

Clinician and review author from Technische Universität München and Medical Center Pain Medicine and Mental Health Saarbrücken, Winfried Häuser, emphasized the need for better quality studies:
 

We need larger, well-designed studies with a treatment duration of at least 12 weeks that include people with comorbid physical illnesses and mental health conditions to fully understand the benefits and harms of cannabis-based medicines. At present, the quality of most of the trials is too poor to draw firm conclusions.

— Winfried Häuser, clinician and author


The authors conclude that the evidence remains weak and uncertain, underscoring the need for higher-quality research before cannabis-based medicines can be recommended for chronic neuropathic pain.

By Mia Parkinson

Source: Cochrane

Categories : IT in Healthcare Pain ManagementTags :

Virtual Reality Nature Walks and “Magic” Hands: A New Era in Pain Management

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Photo by Matteo Vistocco on Unsplash

What if arthritis sufferers could take an immersive walk through a forest filled with soothing birdsong and then, with some help from hypnosis, come to experience their pain as separate from their body – and expel it?

That’s the goal of research led by David Ogez, a professor in the Department of Anesthesiology and Pain Medicine at Université de Montréal and a clinical researcher at the Maisonneuve-Rosemont Hospital Research Centre.

Together with postdoctoral researcher Valentyn Fournier, Ogez is testing an approach that combines medical hypnosis and virtual reality (VR) to help seniors manage chronic arthritis pain in the hands, a common and debilitating condition.

Their research was published online last month in BMJ Open.

“Chronic pain is a major public-health issue that affects about one in five people in Canada and as many as one in three over the age of 60,” said Ogez. “It significantly impacts quality of life, mobility and mental health.  But apart from pharmacological treatments, solutions are few.”

The problem lies in the limitations of drug treatments, including the risk of addiction to painkillers. This led Ogez and his team to explore complementary, non-invasive methods to help patients better manage their pain.

A powerful duo

Medical hypnosis is already recognized as an effective pain management tool, particularly in palliative care and post-operative settings. It relies on hypnotic suggestion—guided phrases that help patients alter their sensory and emotional perception of pain.

For example, patients may be asked to imagine submerging their sore hand in cold water, or be guided through controlled breathing techniques to synchronize their heartbeat and breathing to induce relaxation.

Ogez’s team wanted to take it one step further by combining the power of hypnosis with immersive virtual experiences.

Wearing a headset, the patient is transported to a Quebec landscape—a forest, mountains, a beach—accompanied by music and the sounds of nature. Developed in Quebec, this application was originally designed to give end-of-life patients the opportunity to “visit” places they never had the chance to see in real life.

Pairing hypnosis and VR makes it possible to visualize and manipulate pain, allowing patients to reclaim control of their bodies and their pain, research has shown.

One intervention being tested is the “magic hand.” In virtual reality, patients look at their hand and put little sparkles on the painful area to alleviate the pain. Another intervention involves guiding patients to “objectify” their pain: to make it visible on their hand and then remove it. 

“The pain is still there, but…”

The researchers are also interested in the physiological mechanisms responsible for the pain relief provided by these techniques, which may resemble those associated with mindfulness.

One hypothesis is that VR distracts the brain. By intensely engaging vision, hearing and concentration, VR redirects mental resources that would otherwise be mobilized by pain. Hypnosis then reinforces this diversion of attention by guiding the patient toward pleasant sensations and gradual relief.

Neuroscience research has shown that these techniques modulate the activity of the anterior cingulate cortex and primary somatosensory cortex, two brain regions involved in the emotional and perceptual processing of pain.

“The pain is still there, but its unpleasantness and intensity are reduced,” explained Ogez.

Exposure to nature also provides psychological benefits. “Nature refreshes attention, directing the mind away from negative stimuli and restoring our ability to focus on positive ones,” said Fournier.

Promising preliminary results

Beyond the immediate calming or distracting effects of a treatment session combining hypnosis and VR, the new research aims to help patients develop self-hypnosis skills they can use at home. 

The team is also working on developing a neurofeedback tool that patients can use to track and regulate their brain activity in real time in order to help them modulate their physiological responses during immersive VR experiences. 

While the study is presently in the randomized clinical trial phase, the preliminary feedback from participants is encouraging, said Ogez.

“We’re seeing good patient satisfaction, although we mustn’t confuse satisfaction with effectiveness,” he cautioned. “Still, we’re hopeful, since pain is partly a subjective experience.” 

Categories : Obstetrics & Gynaecology Pain ManagementTags :

New Study Challenges Fears About General Anaesthesia for C-sections

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Data analysed by Penn researchers clarifies risks associated with general anaesthesia, giving patients more control over their delivery experience.

Photo by Anna Shvets on Pexels

Regional anaesthesia has long been favoured for caesarean births due in part to concerns about the effects that general anaesthesia may have on newborns during labour and delivery. Powerful societal pressures also push the idea that mothers need to be awake during delivery to witness the first cry and capture the ‘perfect’ birth moment. But for some women who undergo a caesarean birth, the pain can become excruciating, even after they received a spinal or epidural block.

Now, new research from a team at the Perelman School of Medicine at the University of Pennsylvania, finds that general anaesthesia may be a reasonable alternative for many patients. The findings are published today in Anesthesiology, the peer-reviewed medical journal of the American Society of Anesthesiologists.

“No patient should have to experience pain during caesarean section; as an anaesthesiologist, I never want someone to feel forced to choose between their baby’s health and not having to experience the pain of surgery,” said Mark Neuman, MD, MSc, Professor of Anesthesiology and senior author of the study. “Since regional anaesthesia is so widely used, it’s common for patients to feel that a spinal or epidural block is the only safe option for caesarean section. But as our study shows, anaesthesia type during pregnancy does not need to be one-size-fits-all.”

Reducing pain during C-section delivery

The research analysed 30 years’ worth of data from multiple clinical trials, comparing outcomes between general anaesthesia versus spinal or epidural anaesthesia for C-sections. The Penn study found that, while babies born under spinal or epidural anaesthesia had slightly higher Apgar scores than those born under general anaesthesia, the differences were small and not likely to be clinically meaningful.

While the majority of patients experience good outcomes with spinal or epidural block for caesarean delivery, recent studies show that up to one in six patients who receive an epidural or spinal may feel pain during their C-section. These experiences can be traumatic and have lasting emotional impacts.

The findings come amid growing public discourse on caesarean experiences. Recent podcasts and published news stories have featured candid patient accounts of pain under spinal or epidural anaesthesia. “This study equips women with evidence-based context about the use of general anaesthesia during c-section.” said Sarah Langer, MD, a resident in anaesthesiology at the Perelman School of Medicine and lead author the study. “Childbirth is a physically and emotionally demanding process, but we do not want patients to feel like there aren’t options when it comes to their anaesthesia for c-section,”

Broadening evidence-based choices

The study found that babies born under general anaesthesia were slightly more likely to need breathing support immediately after birth, but there was no increase in NICU admissions. The research does not suggest that general anaesthesia should replace regional techniques, but it can be a reasonable option in certain cases.

“For patients who are open to regional anaesthesia, spinal or epidural block remain great first choice options,” Neuman emphasised. “But having conversations with patients about general anaesthesia doesn’t need to be taboo. Patients deserve to know they have options, and our study helps provide the evidence to support those discussions.”

The authors note that most of the trials included in the analysis were conducted outside North America, highlighting the need for more US-based research in this area. They also point to historical barriers in studying women during pregnancy, which have limited the availability of robust data.

Source: Perelman School of Medicine at the University of Pennsylvania

Categories : Injury & Trauma Pain ManagementTags :

Peri-neuronal Injection of Botulinum Eases Pain in Ukrainian Amputees

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Botulinum injection around neuromas may also be effective for other forms of pain

Photo by Raghavendra V Konkathi on Unsplash

Botulinum toxin injections provided greater short-term relief for phantom limb pain than standard medical and surgical care among Ukrainian war amputees, reports a new study led by Northwestern Medicine and Ukrainian physicians.

The study, which involved 160 amputees treated at two hospitals in western Ukraine between 2022 and 2024, could ultimately benefit millions worldwide, according to the research team.

Post-amputation pain affects most amputees. The condition limits prosthetic use, mobility and quality of life. In the US, more than 2 million people live with limb loss. In Ukraine, it is estimated that over 100 000 soldiers and civilians have lost limbs since Russia’s full-scale invasion, which began in 2022.

“Botulinum toxin injected into painful stumps of residual limbs and around neuromas was on some outcome measures more effective than comprehensive medical and surgical treatment at one month post-treatment,” said senior study author Dr Steven P. Cohen, a professor of anaesthesiology and the vice chair of research and pain medicine at Northwestern University Feinberg School of Medicine.

Dr. Steven Cohen is a retired U.S. Army colonel who traveled to Ukraine to collaborate with local doctors.

“Our results show that botulinum toxin potentially could be a powerful short-term tool for treating post-amputation pain when used alongside comprehensive medical and surgical care,” said co-author Dr. Roman Smolynets, an anesthesiologist and intensive care specialist at Multidisciplinary Clinical Hospital of Emergency and Intensive Care in Lviv, Ukraine.

“It could be another step toward helping amputees live with less pain and more dignity. But always as an additional point to comprehensive medical and surgical care, not as a monotherapy.”

The study was published in the journal Archives of Physical Medicine and Rehabilitation.

Assessing pain before and after treatments

All study participants were amputees treated at the First Medical Union of Lviv or Ivano-Frankivsk Regional Hospital. About one-fifth received botulinum toxin injections around painful nerve endings, called neuromas, in addition to standard medical and physical therapy. The other participants received comprehensive medical and surgical treatment, which included surgical revision, nerve blocks, physical and psychological therapy, medications and other interventional procedures.

The research team assessed pain levels at the start of treatment and after one and three months, focusing separately on phantom limb pain (pain in the missing limb) and residual limb pain (pain at the stump site).

At one month, the botulinum toxin group experienced an average reduction of four points in phantom limb pain on a 10-point scale, compared with just one point among patients in the comparison group. Also at one month, 69% of patients who received botulinum toxin achieved a meaningful improvement (defined as at least a 30% drop in pain) in phantom limb pain, versus only 43% in the other patient group.

However, the results shifted at three months: Patients who received comprehensive care showed more durable pain relief than the botulinum toxin group, consistent with previous research showing that botulinum toxin’s pain-relieving effects typically last about three months.

A novel way to inject botulinum toxin

While botulinum toxin injections, a non-surgical treatment that alleviates pain by blocking nerve signals, are most commonly known for their use in cosmetic procedures, they are also an established tool to treat chronic pain.

In the study, the substance was injected in a novel way. The research team used ultrasound guidance to inject botulinum toxin directly around painful nerve endings and surrounding soft tissues, rather than into muscle or skin. This targeted “peri-neuromal” approach, the scientists believe, may explain the strong short-term reduction in pain by quieting nerve activity and local inflammation. Previous studies have shown botulinum toxin to be effective for neuropathic pain, but none injected it around painful nerves.

The new findings suggest that botulinum toxin injections near nerves may also help relieve other types of nerve pain, such as shingles-related pain, carpal tunnel syndrome and pain following surgeries like mastectomy or thoracotomy.

Friendship with a Ukrainian anaesthesiologist

Cohen, who traveled to Ukraine in 2024 to help launch the study, is a retired U.S. Army colonel who served four overseas tours in support of military operations; his son currently serves with the infantry.

In Ukraine, he partnered with Smolynets, who has treated thousands of soldiers and civilians injured in the war by working in the country’s largest trauma and emergency center, and Dr. Nadiya Segin, who is pioneering the use of Botulinum toxin and nerve stimulation to treat war injuries.

Smolynets will visit Chicago the week of Oct. 19 with a Ukrainian delegation for an observership program, spending time with Cohen at his pain medicine clinic and at a Shirley Ryan AbilityLab in downtown Chicago. The two physicians, now close friends, are available for interviews during that week.

More research in Ukraine

Cohen and his colleagues stress the need for larger, randomized trials to confirm their findings, refine patient selection and optimize botulinum toxin dosing. Future research should also explore whether repeat botulinum toxin injections over time could produce sustained benefits for post-amputation pain, as they appear to do for migraine treatment.

Cohen and Smolynets, who published another study in February about using hydrodissection for post-amputation pain in Ukraine, are also researching more novel war treatments in Ukraine, at Walter Reed, and Northwestern, for traumatic brain injury and PTSD. These studies are underway. 

“As a retired colonel and the father of an infantry soldier who could be deployed in future conflicts and suffered from traumatic brain injury while at the U.S. Military Academy, this research carries special personal meaning for me,” Cohen said.

Source: Northwestern University