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.
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.
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.
Photo by Barbara Olsen on Pexels
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.
A new method has been developed that could non-invasively ease pain, avoiding the side effects of pain medication and the addiction problems associated with current opioid pain relievers.
This new study by Wynn Legon, assistant professor at the Fralin Biomedical Research Institute at Virginia Tech, and his team targets the insula, the location for pain reception deep within the brain. Their study, published in the journal PAIN, found that soundwaves from low-intensity focused ultrasound aimed at this spot can reduce both the perception of pain and other effects of pain, such as heart rate changes.
“This is a proof-of-principle study,” Legon said. “Can we get the focused ultrasound energy to that part of the brain, and does it do anything? Does it change the body’s reaction to a painful stimulus to reduce your perception of pain?”
Unlike ultrasound scans, focused ultrasound delivers a narrow band of sound waves to a tiny point. At high intensity, ultrasound can ablate tissue. At low-intensity, it can cause gentler, transient biological effects, such as altering nerve cell electrical activity
Neuroscientists have long studied how non-surgical techniques, such as transcranial magnetic stimulation, might be used to treat depression and other issues. Legon’s study, however, is the first to target the insula and show that focused ultrasound can reach deep into the brain to ease pain.
The study involved 23 healthy human participants. Heat was applied to the backs of their hands to induce pain. At the same time, they wore a device that delivered focused ultrasound waves to a spot in their brain guided by magnetic resonance imaging (MRI).
Participants rated their pain perception in each application on a scale of zero to nine. Participants reported an average reduction in pain of three-fourths of a point.
“That might seem like a small amount, but once you get to a full point, it verges on being clinically meaningful,” said Legon, also an assistant professor in the School of Neuroscience in Virginia Tech’s College of Science.
“It could make a significant difference in quality of life, or being able to manage chronic pain with over-the-counter medicines instead of prescription opioids.”
Researchers also monitored each participant’s heart rate and heart rate variability as a means to discern how ultrasound to the brain also affects the body’s reaction to a painful stimulus.
The study also found the ultrasound application reduced physical responses to the stress of pain – heart rate and heart rate variability, which are associated with better overall health.
“Your heart is not a metronome. The time between your heart beats is irregular, and that’s a good thing,” Legon said.
“Increasing the body’s ability to deal with and respond to pain may be an important means of reducing disease burden.”
The effect of focused ultrasound on those factors suggests a future direction for the Legon lab’s research – to explore the heart-brain axis, or how the heart and brain influence each other, and whether pain can be mitigated by reducing its cardiovascular stress effects.
Neuropathic pain is one of the hardest types of pain to alleviate – many of the available pain medications are only moderately effective and often come with serious side effects, as well as risk of addiction.
Now researchers at UT Austin, The University of Texas at Dallas and the University of Miami have identified a molecule that reduces hypersensitivity in trials in mice by binding to a protein they have shown is involved in neuropathic pain. The findings appear in the journal Proceedings of the National Academy of Sciences.
“We found it to be an effective painkiller, and the effects were rather long-lived,” said Stephen Martin, co-corresponding author of the paper at The University of Texas at Austin.
“When we tested it on different models, diabetic neuropathy and chemotherapy-induced neuropathy, for example, we found this compound has an incredible beneficial effect.”
The new compound, dubbed FEM-1689, does not engage opioid receptors in the body, making it a possible alternative to existing pain medications linked to addiction.
In addition to reducing sensitivity, the compound can help regulate the integrated stress response (ISR), a network of cellular signaling that helps the body respond to injuries and diseases.
When well regulated, the ISR restores balance and promotes healing. When it goes awry, the ISR can contribute to diseases such as cancer, diabetes and metabolic disorders.
“It’s our goal to make this compound into a drug that can be used to treat chronic pain without the dangers of opioids,” Martin said.
“Neuropathic pain is often a debilitating condition that can affect people their entire lives, and we need a treatment that is well tolerated and effective.”
A systematic review published in the Canadian Medical Association Journal revealed that while people had good odds of recovering from short term back pain, but if it becomes persistent, then the chances of recovery are greatly reduced. This has important implications for the treatment of chronic back pain, as it points to the pain from the original injury being replaced by pain hypersensitivity.
“The good news is that most episodes of back pain recover, and this is the case even if you have already had back pain for a couple of months,” University of South Australia Professor Lorimer Moseley says.
“The bad news is that once you have had back pain for more than a few months, the chance of recovery is much lower. This reminds us that although nearly everyone experiences back pain, some people do better than others, but we don’t completely understand why.”
The systematic review and meta-analysis, conducted by an international team of researchers, included 95 studies with the goal of understanding the clinical course of acute (< 6 weeks), subacute (six to less than 12 weeks) and persistent (12 to less than 52 weeks) low back pain.
For people with new back pain, pain and mobility problems lessened significantly in the first six weeks, but then recovery slowed.
This study filled a gap in a 2012 paper from the same research team, with new findings showing that many people with persistent low back pain (more than 12 weeks) continue to have moderate-to-high levels of pain and disability.
“These findings make it clear that back pain can persist even when the initial injury has healed,” Prof Moseley says.
“In these situations, back pain is associated with pain system hypersensitivity, not ongoing back injury. This means that if you have chronic back pain – back pain on most days for more than a few months – then it’s time to take a new approach to getting better.”
He notes that there are new treatments based on training both the brain and body that “focus on first understanding that chronic back pain is not a simple problem, which is why it does not have a simple solution, and then on slowly reducing pain system sensitivity while increasing your function and participation in meaningful activities.”
The authors state that identifying slowed recovery in people with subacute low back pain is important so that care can be escalated and the likelihood of persistent pain reduced.
Further research into treatments is needed to help address this common and debilitating condition, and to better understand it in people younger than 18 and older than 60 years.
There does not appear to be any profound differences between so-called exposure-based CBT and traditional CBT in the treatment of fibromyalgia, according to a study led by researchers at Karolinska Institutet. Both forms of treatment produced a significant reduction in symptoms in people affected by the disease. The study, one of the largest to date to compare different treatment options for fibromyalgia, is published in the journal PAIN.
About 2–4% of people live with fibromyalgia, a long-term pain syndrome that causes great suffering for patients through widespread pain, fatigue, and stiffness in the body. There is no cure for fibromyalgia and existing drugs often have insufficient effect, raising the need for more effective treatment methods.
Cognitive behavioural therapy (CBT) has shown some effect, but there is a lack of trained CBT practitioners. There is also a lack of knowledge about which form of CBT is most effective.
The study compared two different forms of internet-delivered cognitive behavioral therapy in terms of how well they reduce the symptoms and functional impact of fibromyalgia.
In brief, exposure-based CBT involves the participant systematically and repeatedly approaching situations, activities, and stimuli that the patient has previously avoided because the experiences are associated with pain, psychological discomfort, or symptoms such as fatigue and cognitive problems.
In traditional CBT, the participant is presented with several different strategies to work on during treatment, such as relaxation, activity planning, physical exercise, or strategies for managing negative thoughts and improving sleep.
The study showed that traditional CBT was by and large equivalent to the newer treatment form of exposure-based CBT.
“This result was surprising because our hypothesis, based on previous research, was that the new exposure-based form would be more effective. Our study shows that the traditional form can provide an equally good result and thus contributes to the discussion in the field,” says Maria Hedman-Lagerlöf, licensed psychologist and researcher at the Center for Psychiatry Research at the Department of Clinical Neuroscience, Karolinska Institutet.
The randomized study involved 274 people with fibromyalgia, who were randomly assigned to be treated with traditional or exposure-based CBT.
The treatments were delivered entirely online and all participants had regular contact with their therapist.
Participants answered questions about their mood and symptoms before, during, and after treatment.
After the 10-week treatment, 60% of those who received exposure-based CBT and 59% of those who received traditional CBT reported that their treatment had helped them.
“The fact that both treatments were associated with a significant reduction in the participants’ symptoms and functional impairment and that the effects were sustained for 12 months after completion of the treatment, indicates that the internet as a treatment format can be of great clinical benefit for people with fibromyalgia,” says Maria Hedman-Lagerlöf. “This is good news because it enables more people to access treatment.”
The study is the second largest to compare different psychological treatment options for fibromyalgia, according to the researchers.
“Our study is also one of the first to compare with another active, established psychological treatment,” says Maria Hedman-Lagerlöf.
Post-surgery pain relief has shifted away from opioid-containing medications over the past seven years, but the downward trend has slowed since 2020, a new University of Michigan study shows.
Overall, the rate of surgery-related opioid prescriptions dropped by 36% from 2016 to the end of 2022, and the average amount of opioids in those prescriptions dropped by 46%, the study of pharmacy data finds.
That combination of declines means that the total amount of opioids dispensed to surgical patients in late 2022 was 66% lower compared with early 2016, according to the findings published in JAMA Network Open.
But the rate of decline was much faster before the pandemic, the researchers report after comparing surgical opioid patterns before and after 2020.
That’s even after they took into account the unusual circumstances of spring 2020, when most elective surgery temporarily stopped to free up hospital capacity for COVID-19 patients and reduce unnecessary exposure to the SARS-CoV-2 virus.
Even with the overall declines, American surgery patients in late 2022 still received the equivalent of 44 5-milligram pills of hydrocodone from pharmacies after their operations on average.
That’s far higher than what patients need for most procedures.
“These data suggest surgical teams have substantially reduced opioid prescribing, but also suggest that efforts to right-size opioid prescriptions after surgery must continue,” said Kao-Ping Chua, M.D., Ph.D., the senior author of the new study and an assistant professor of pediatrics at U-M. He worked with first author and former U-M research assistant Jason Zhang, who is now in medical school at Northwestern University.
The researchers also find that some types of surgeons have reduced the amount of opioids dispensed to patients more than others.
For instance, reductions were particularly large in cardiothoracic surgery and ophthalmology.
Orthopedic surgeons still account for more than half of all surgical opioids dispensed to American patients, even as the rate and size of prescriptions filled by their patients dropped.
Right-sizing prescribing
The authors note that surgeons should not strive to eliminate opioid prescribing altogether.
“The goal should be to ensure that opioids are only prescribed when necessary, and that the amount of opioids prescribed matches the amount that patients need,” said Zhang.
“Achieving these goals could help reduce the risk of opioid misuse, persistent opioid use, and diversion of pills to other people besides the patient.”
The potential for accidental exposure to opioids by others in the household, and interactions between opioids and other substances including alcohol and prescription drugs, are other reasons to focus on non-opioid surgical pain care.
Chua and colleagues have studied procedure-related opioid prescribing multiple times, including a recent study showing that the reduction in the rate of dental opioid prescribing has similarly slowed in recent years.
Surgical organisations and the Centers for Disease Control and Prevention have advised surgeons to rely less on opioid-based acute pain relief for their patients since the mid-2010s.
But no studies have examined surgical opioid prescribing trends using pandemic-era data.
The new study is based on data from a company called IQVIA that tracks prescriptions dispensed at 92% of US pharmacies.
The number of patients admitted with opioid use disorder (OUD) and injection-related infections who left the hospital before completing treatment increased significantly between 2016 and 2020 (from 9.3% to 17%) according to analysis from researchers at the Perelman School of Medicine at the University of Pennsylvania. One in six of these patients now leave the hospital before medically advised (BMA).
The findings, published in JAMA, also reveal that the rate at which patients with any opioid-related issues (patients presenting with other issues but exhibiting opioid dependence) left the hospital BMA increased more than 50% (from 7.5 to 11.3%). In both of these groups, nearly half of BMA discharges occurred before the third day, when withdrawal symptoms are most severe. Now that fentanyl has become the dominant opioid causing overdoses, the findings illustrate the need for patient-centred care that adequately manages pain and withdrawal symptoms so that patients can complete treatment.
Approximately 500 000 patients are discharged against medical advice, or in the United States annually, and those circumstances are associated with increased likelihood of death and hospital readmission. Previous research shows that patients with addiction cite withdrawal and pain as their reason for BMA discharge.
“The rapid increase in early discharges is alarming; in 2016, less than one in ten patients admitted for OUD and injection-related infections left the hospital before their care team considered it safe. By 2020, one in six were leaving early,” said lead author Ashish Thakrar, MD. “What’s more, since the study period ended, the COVID-19 pandemic caused the opioid crisis to escalate, underscoring just how urgent it is to understand how we might be able to reverse this trend and get patients the treatment they need.”
Using nationally representative data from the National Readmissions Database, researchers compared the rate of discharge BMA in patients admitted for OUD to the BMA discharge rate for non-opioid admissions. They also evaluated changes in the proportion of BMA discharges before the third admission day, when opioid withdrawal is most severe, and changes in the proportion of discharges BMA in patients with stimulant use disorder.
They identified opioid-related admissions as those with opioid use, dependence, abuse, or overdose. To account for patients who were more likely to have severe OUD and fentanyl use, they also included patients with OUD and an injection related infections, such as bacteraemia, endocarditis, or osteomyelitis.
Between 2016 and 2020, they found that the number of patients admitted with OUD and injection-related infections who left the hospital BMA increased 82%, from 9.3% to 17%. They also found that the discharge BMA rate for all opioid-related admissions increased 50% during this period, from 7.5% to 11.3%. The proportion of BMA discharges occurring before the third day also increased for individuals with OUD and an injection-related infection, from 42.6%, to 48%.
In contrast, the BMA rate increased only marginally for non-opioid mental health or substance use admissions, and all non-opioid admissions (from 3.1 to 3.5%, and 1.1 to 1.5%, respectively).
“These data didn’t allow us to discern which type of opioid that individuals were using when admitted for OUD, but we know that fentanyl, an opioid 25 to 50 times more potent than heroin, has spread in unregulated drug supplies and is now involved in 88 percent of opioid overdoses in the US. Withdrawal symptoms from fentanyl are more difficult to manage than from other opioids like heroin and oxycodone,” said Thakrar. “This study illustrates why we need more research on how to manage individuals withdrawing from fentanyl and other substances in the unregulated drug supply.”
“The drugs that individuals are using have changed over the past decade, and how we treat them should change, too,” said senior author M. Kit Delgado, MD, MS. “Health systems can expand the use of interventions that are already proven to treat withdrawal and reduce but not widely used, such as medications like buprenorphine and methadone.”
Thakrar and Delgado also suggest that hospitals could be incentivised to reduce discharges BMA and to support specialty services such as addiction consult services that have been proven to reduce BMA discharges and that can reduce the risks of future readmission or death.
Researchers have identified objective evidence of how the neck muscles are involved in primary headaches. The study findings, being presented at the annual meeting of the Radiological Society of North America (RSNA), could lead to better treatments.
The distinct underlying causes of primary headaches, comprising tension-type headaches and migraines, are still not fully understood.
“Our imaging approach provides first objective evidence for the very frequent involvement of the neck muscles in primary headaches, such as neck pain in migraine or tension-type headache, using the ability to quantify subtle inflammation within muscles,” said Nico Sollmann, MD, PhD, resident at University Hospital Ulm and University Hospital Rechts der Isar in Munich, Germany.
In tension-type headaches there is often the perception of a tightening in the head and mild to moderate dull pain on both sides of the head. While these headaches are typically associated with stress and muscle tension, their exact origin is not fully understood.
Migraines are characterised by a severe throbbing pain and generally occur or are worse on one side of the head. Migraines may also cause nausea, weakness and light sensitivity.
Neck pain is commonly associated with primary headaches but there are no objective biomarkers for myofascial involvement. Myofascial pain is associated with inflammation or irritation of muscle or of the connective tissue, known as fascia, that surrounds the muscle.
For the study, Dr Sollmann and colleagues aimed to investigate the involvement of the trapezius muscles in primary headache disorders by quantitative magnetic resonance imaging (MRI) and to explore associations between muscle T2 values and headache and neck pain frequency.
The prospective study recruited 50 participants, mostly women, ranging in age from 20 to 31 years old. Of the participants, 16 had tension-type headache, and 12 had tension-type headache plus migraine episodes. The groups were matched with 22 healthy controls.
All participants underwent 3D turbo spin-echo MRI. The bilateral trapezius muscles were manually segmented, followed by muscle T2 extraction.
Associations between muscle T2 values and the presence of neck pain, number of days with headache, and number of myofascial trigger points as determined by manual palpation of the trapezius muscles were analysed (adjusting for age, sex and body mass index).
The tension-type headache plus migraine group demonstrated the highest muscle T2 values. Muscle T2 was significantly associated with the number of headache days and the presence of neck pain.
The increased muscle T2 values could be interpreted as a surrogate of inflammation arising from the nervous system and increased sensitivity of nerve fibres within myofascial tissues.
“The quantified inflammatory changes of neck muscles significantly correlate with the number of days lived with headache and the presence of subjectively perceived neck pain,” Dr Sollmann said.
“Those changes allow us to differentiate between healthy individuals and patients suffering from primary headaches.”
Muscle T2 mapping could be used to stratify patients with primary headaches and to track potential treatment effects for monitoring.
“Our findings support the role of neck muscles in the pathophysiology of primary headaches,” Dr Sollmann said. “Therefore, treatments that target the neck muscles could lead to a simultaneous relief of neck pain, as well as headache.”
Dr Sollmann pointed out that non-invasive treatment options that directly target the site of pain in the neck muscles could be highly effective and safer than systemic drugs.
“Our imaging approach with delivery of an objective biomarker could facilitate therapy monitoring and patient selection for certain treatments in the near future,” he added.
