Tag: pain management

Categories : Paediatrics Pain ManagementTags : Leave a comment

Ways to Reduce Kids’ Needle-related Fear and Pain

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Image of a syring for vaccination
Photo by Mika Baumeister on Unsplash

In the COVID era, when vaccinations are all the more important, new research published in the European Journal of Pain shows that children’s vaccination and needle fear can be reduced with a couple of different techniques used by nurses.

These techniques divide the children’s attention or redress their fears by framing the positive elements of their experience.

Working with children aged 8–12 years, the preliminary study found that two new nurse-led techniques show promise in reducing needle fear in primary-aged children:

  • Divided Attention – where a child’s attention and expectations are drawn away from the needle.
  • Positive Memory Reframing – where a child’s exaggerations about the distress and discomfort of needles are redressed through discussion about the positive elements of the experience so that the form more realistic memories of the event.

Dr Felicity Braithwaite, lead researcher of the study, said that helping children reduce fear and distress around vaccinations is a key area of research in the COVID era.

“For many children, undergoing a needle procedure can be painful and distressing,” Dr Braithwaite said.

“Negative experiences of vaccinations in childhood can often lead to medical avoidance and vaccine hesitancy into adulthood, which can have devastating consequences when it comes to outbreaks of preventable diseases.

“By investing more time into techniques to help children manage their fears about needles, we hope to change these outcomes and deliver better health outcomes for the next generation.”

The study involved 41 children and their parents, with participants randomised to one of four groups – usual care, divided attention, positive memory reframing, or a combination of the latter two interventions. Clinical outcomes were assessed at baseline, immediately post-vaccination and at two-weeks post-vaccination. 

The Divided Attention technique involved a one to two minute distraction game where a nurse tapped the child’s arm above and below the vaccination spot in a random order, with the child focussing their attention on guessing which spot was touched each time. This game takes advantage of the potential analgesic effects of distraction.

The Positive Memory Reframing technique involved talking to children about a past injection and emphasising positive aspects, such as how brave the child was and praising specific strategies they used to reduce their own distress, for example, deep breathing and looking away. The aim is to foster a sense of self-efficacy to help children better cope.

Both techniques were tested outside of clinical locations, such as in schools, to maximise their applicability in real-world settings.

Source: University of South Australia

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Clinical Trial Finds Dry Cupping Relieves Chronic Back Pain

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Photo by RODNAE Productions

In the Journal of Acupuncture and Meridian Studies, researchers report that combining ear acupuncture with dry cupping to treat chronic back pain, and showed that it can provide effective relief over acupuncture alone.

Dating back to ancient times, cupping therapy is a technique that uses cups placed over the skin to create negative pressure through suction. In 400 BC, Herodotus listed wet and dry cupping as a treatment for many ailments, including maldigestion, lack of appetite, and headaches. Ear acupuncture, also known as ‘battlefield acupuncture’ has also been modernised by the US military as a simple treatment method in challenging environments.

The open-label, randomised, parallel-group controlled clinical trial recruited 198 adults with chronic back pain. The people were randomised to receive only ear acupuncture as the control group or receive ear acupuncture along with dry cupping as the experimental group.

Interventions were performed in five sessions, once a week, lasting five weeks. Evaluations were performed before the first session, after the last session, and seven days after the second evaluation, using the Brief Pain Inventory to assess the impact of pain on daily activities and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) to assess the quality of life.

Between the initial and final sessions, there were significant changes in daily activities , activity, work, mood, relationships, sleep, and in the physical, psychological and social relationships domains for both the control and experimental groups. Improved perception of quality of life and satisfaction with health were observed for the participants in the experimental group.

Source: Keck School of Medicine USC

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Mechanism Behind Sound and Pain Suppression Identified in Mice

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Photo by Sergio Capuzzimati on Unsplash

Sound is known to suppress the sensation of pain, and now scientists have identified the neural mechanisms through which sound blunts pain in mice. The findings, which could inform development of safer methods to treat pain in humans, were published in Science.

“We need more effective methods of managing acute and chronic pain, and that starts with gaining a better understanding of the basic neural processes that regulate pain,” said the director of the National Institute of Dental and Craniofacial Research (NIDCR), Rena D’Souza, DDS, PhD. “By uncovering the circuitry that mediates the pain-reducing effects of sound in mice, this study adds critical knowledge that could ultimately inform new approaches for pain therapy.”

Studies as far back as 1960, have shown that music and other kinds of sound can help alleviate acute and chronic pain in humans, including pain from dental and medical surgery, labour and delivery, and cancer. Yet the mechanism behind this remained elusive.

“Human brain imaging studies have implicated certain areas of the brain in music-induced analgesia, but these are only associations,” said co-senior author Yuanyuan (Kevin) Liu, PhD, at NIDCR. “In animals, we can more fully explore and manipulate the circuitry to identify the neural substrates involved.”

The researchers first exposed mice with inflamed paws to three types of sound: a pleasant piece of classical music, an unpleasant rearrangement of the same piece, and white noise. Surprisingly, all three types of sound, when played at a low intensity relative to background noise (about the level of a whisper) reduced pain sensitivity in the mice. Higher volume had no effect on their pain sensitivity.

Researchers discover how sound reduces pain in mice
Inhibition of auditory cortex inputs to the thalamus drives sound-induced analgesia. Credit: Conghuan Ye

“We were really surprised that the intensity of sound, and not the category or perceived pleasantness of sound would matter,” Dr Liu said.

To explore the brain circuitry underlying this effect, the researchers trace connections between brain regions using fluorescent protein-tagged viruses. They identified a route from the auditory cortex to the thalamus, which relays sensory signals, including pain, from the body. In freely moving mice, low-intensity white noise reduced the activity of neurons at the receiving end of the pathway in the thalamus.

Without sound, suppressing the pathway with light- and small molecule-based techniques mimicked the pain-blunting effects of low-intensity noise, while turning on the pathway restored animals’ sensitivity to pain.

Dr Liu said it is unclear if similar brain processes are involved in humans, or whether other aspects of sound, such as its perceived harmony or pleasantness, are important for human pain relief.

“We don’t know if human music means anything to rodents, but it has many different meanings to humans – you have a lot of emotional components,” he said.

The results could give scientists a starting point for studies to determine whether the animal findings apply to humans, and ultimately could inform development of safer alternatives to opioids for treating pain.

Source: National Institutes of Health

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Cannabis is Moderately Effective for Chronic Pain, Review Finds

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Cannabis’s pain reduction effects appear to be less effective than previously though. Photo by Kindel Media

Cannabis product use provides modest, short-term improvements in chronic pain, albeit with some side effects, according to a large review of research on cannabis pain management. The review also revealed a general lack of high quality evidence such as randomised controlled trials (RCTs). The data will be uploaded to a web app made by Oregon Health & Science University to inform clinicians on cannabis medications.

Reporting in Annals of Internal Medicine, researchers found evidence to support a short-term benefit in treating neuropathic pain with two synthetic products with 100% tetrahydrocannabinol (THC): dronabinol (under the trade name Marinol) and nabilone (Cesamet). Another product, a sublingual spray of equal parts THC and cannabidiol (CBD), known as nabiximols, also showed evidence of some clinical benefit for neuropathic pain. All of the products had side effects, such as nausea, sedation and dizziness.

From 3000 studies, the researchers selected RCTs or comparative observational studies of patients with chronic pain that compared cannabis products with a placebo or no treatment (that is, usual care) for at least 4 weeks of treatment or follow-up.

They ended up with a total of 25 with scientifically valid evidence – 18 RCTs and seven observational studies. Cannabinoids were categorised as high, comparable, or low THC-to-CBD ratio. The researchers found:

  • Synthetic products with high THC (> 98%) and little or no CBD: moderate improvement in pain, but greater sedation risk and possible increase in dizziness
  • Extracted products with majority THC (THC:CBD ratio ranging from 3:1 to 47:1): no significant improvement in pain, but greater study withdrawal because of adverse events and dizziness
  • Sublingual sprays with comparable THC and CBD levels: small improvement in pain but a much greater increased risk of dizziness and sedation and a moderate increase in nausea

Besides these findings, there was little evidence to support any other conclusions.

“In general, the limited amount of evidence surprised all of us,” said lead author Marian S. McDonagh, PharmD, emeritus professor at OHSU. “With so much buzz around cannabis-related products, and the easy availability of recreational and medical marijuana in many states, consumers and patients might assume there would be more evidence about the benefits and side effects.

“Unfortunately, there is very little scientifically valid research into most these products. We saw only a small group of observational cohort studies on cannabis products that would be easily available in states that allow it, and these were not designed to answer the important questions on treating chronic pain.”

“For some cannabis products, such as whole-plant products, the data are sparse with imprecise estimates of effect and studies had methodological limitations,” the authors noted.

This situation makes it difficult to guide patients.

“Cannabis products vary quite a bit in terms of their chemical composition, and this could have important effects in terms of benefits and harm to patients,” said co-author Roger Chou, MD. “That makes it tough for patients and clinicians since the evidence for one cannabis-based product may not be the same for another.”

The living review, including a visual abstract summary of the findings, will also be shared on a new web-based tool launched by OHSU and VA Portland Health Care System early this year to help clinicians and researchers evaluate the latest evidence around the health effects of cannabis. Known as Systematically Testing the Evidence on Marijuana, or STEM, the project includes ‘clinician briefs’ to help health care workers translate the clinical implications.

“This new living evidence review is exactly the type of resource clinicians need to clarify for patients the areas of potential promise, the cannabis formulations that have been studied and, importantly, the major gaps in knowledge,” said co-author Devan Kansagara, MD, MCR, professor of medicine at OHSU.

Source: Oregon Health & Science University

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Opioid Misuse in Young Sarcoma Patients

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Depression, young man
Source: Andrew Neel on Unsplash

Nearly a quarter of young patients prescribed opioids while being treated for sarcoma continue to use opioids after treatment is completed according to findings published in CANCER, highlighting the need for safe deprescribing.

Individuals with sarcoma, a type of cancer in the bones or soft tissues, often develop damaged and fractured bones and undergo major surgical operations, and physicians may prescribe opioids for pain management. It was not clear whether doing so raises the risk for opioid misuse and overdose in these young patients. 

Melissa Beauchemin, PhD, RN, CPNP-PC, CPON, of Columbia University School of Nursing, and her colleagues sought to determine the rate of new persistent opioid use among adolescents and young adults treated for sarcoma. Persistent opioid use was defined as at least two opioid prescriptions in the 12 months after treatment was completed.  

The team drew from a large insurance claims database to analyse information on patients aged 10–26 years old who had not received prior opioids and who were diagnosed with sarcoma between 2008 and 2016.  

Among the 938 patients in the analysis, 64% received opioid prescriptions during treatment. After completing cancer therapy, 14% of patients overall and 23% of those who used opioids during treatment continued to use opioids and met the criteria for new persistent use. Being covered by Medicaid versus commercial insurance, having bone tumours versus soft tissue tumours, and receiving concurrent lorazepam (often prescribe to treat anxiety and sleeping problems) were associated with persistent opioid use. 

“Adolescents and young adults are a vulnerable population because they have benefitted less than younger and older cancer patients from recent advances. These results highlight the need to monitor young patients with sarcoma for posttreatment opioid use, given the potential negative impacts of long-term opioid use, including misuse and overdose,” said Dr Beauchemin. “Age- and developmentally appropriate strategies to effectively manage pain while minimising opioid exposure are urgently needed.” 

Dr Beauchemin stressed that for young people needing opioids for effective pain management, early and safe discontinuation of opioids should be prioritised. “Further, there is a critical need for clinical practice guidelines to support clinical decision making to safely and effectively manage pain specifically for adolescents and young adults with cancer,” she said. 

Source: Wiley

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The Claustrum: A Mysterious Brain Region Involved with Pain

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Man wearing mask with headache
Source: Usman Yousaf on Unsplash

A new review paper, published in the journal Brain, has shown that a mysterious brain region called the claustrum may play an important role in the experience of pain. This densely interconnected, but difficult to access area of the brain may be the next frontier in improving outcomes for brain damage patients.

The claustrum is a brain region that has been investigated for over 200 years, yet its precise function remains unknown. A 2005 article suggested it to be critically linked to consciousness, which spurred a renewed interest in this region, with recent research revealing its high level of interconnectedness.

Credit: Oxford University

Oxford University researchers reviewed studies of patients with rare cases of lesions in the claustrum, which show cognitive impairments and seizures. There may be many more cases to be uncovered due to the lack of clinical focus on the claustrum.

They also uncovered an underappreciated link between the claustrum and pain. It is already known that there are links between the claustrum and perception, salience and the sleep-wake cycle, but this is the first time a research team has shown how the claustrum might be more involved in the debilitating experience of pain.

Dr. Adam Packer, the lead author of the study, says that “The problem with understanding how the claustrum works is that it is deep inside the brain, and damage that is specific to it is a very rare occurrence. What makes it more difficult to work out what the claustrum actually does is that these rare occurrences are also linked to such a broad range of symptoms.”

“Clearly, when the claustrum is damaged the effects are severe and better therapies are urgently needed. It is possible that claustrum damage is more common than we currently realise, and it may be a crucial component in many more brain damage cases.”

“This work is important because it gives us some insight into the cognitive and neurological processes in which the claustrum may be involved, and gives us targets to pursue in basic research in the lab.”

The researchers found several recorded instances of either infection, autoimmune, or other process that attacked the claustrum in particular, and by analysing the results of these studies and others the most common symptoms in patients were cognitive impairment and seizures.

Additional research is needed for a better understanding of the claustrum and the impact of damage to the claustrum, which could eventually change clinical guidelines.

Source: University of Oxford

Categories : Injury & Trauma Pain ManagementTags : Leave a comment

Chronic Pain in Spinal Cord Injury Increases Mental Health Risk

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Having a spinal cord injury increases risk of developing mental health conditions such as depression and anxiety by nearly 80% compared to those without the traumatic injury, a new study shows. However, chronic pain may have an equally large, negative effect on mental health.

The study, published in Spinal Cord, compared private insurance claims from more than 9000 adults with a traumatic spinal cord injury with those of more than 1 million without. Researchers accounted for a range of psychological conditions, from anxiety and mood disorders to insomnia and dementia.

People living with a spinal cord injury had a diagnosis of a mental health condition more often than those without – 59.1% versus 30.9%. While depression and adverse mental health effects are not inevitable consequences of every traumatic spinal injury, previous studies have consistently echoed higher levels of psychological morbidity among this group than the general population without spinal cord injuries.

However, this study found that chronic centralised and neuropathic pain among adults living with a spinal cord injury were robustly associated with post-traumatic stress disorder, substance use disorders and other mental health conditions. In most cases, chronic pain was an even greater influence on these conditions than exposure to living with the injury itself.

The study authors said the findings should prompt physicians to identify mental health conditions when seeing patients with spinal cord injuries and refer them for treatment.

“Improved clinical efforts are needed to facilitate screening of, and early treatment for, both chronic pain and psychological health in this higher-risk population,” said lead author Dr Mark Peterson, associate professor of physical medicine and rehabilitation at Michigan Medicine.

However, researchers note a lack of insurance coverage and limited available services will likely cause the issue to remain largely unaddressed.

“Stakeholders need to work together to lobby for more federal research funding and special policy amendments to ensure adequate and long-term insurance coverage for both physical and mental health to meet the needs of folks living with spinal cord injuries,” Dr Peterson said.

Source: EurekAlert!

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Duloxetine Flops for Osteoarthritis Pain Relief

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Photo by Nino Liverani on Unsplash

A new study found that duloxetine, a medication that is prescribed to treat depression and may also reduce chronic pain, did not benefit patients with hip or knee osteoarthritis.

Off-label uses for duloxetine include chemotherapy-induced peripheral neuropathy and stress urinary incontinence. It is in the Serotonin and norepinephrine reuptake inhibitors (SNRIs) class of medications. 

An open label, cluster randomised trial was conducted in patients experiencing chronic osteoarthritis-related pain in the hip or knee that did not go away with paracetamol and NSAIDs. Of 133 patients, 66 were assigned to duloxetine 60mg/day plus usual care and 66 were assigned to only usual care. 

The findings, published in Arthritis & Rheumatology howed that duloxetine did not lessen WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain at 3 months or 12 months. For the subgroup of patients with symptoms of centralised pain no effect of duloxetine was found either.

“There was no clinically relevant effect of duloxetine added to usual care compared to usual care alone for chronic osteoarthritis pain, and it should not be implemented,” the authors concluded.

Source: Wiley

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Leafy Vegetable-rich Diet Could Curb Migraine Symptoms

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Source: Pixabay

It may be worth adopting a plant based diet, rich in dark green leafy vegetables, to ease the symptoms of chronic migraine, suggest doctors reporting on a case study.

Writing in BMJ Case Reports, the doctors’ recommendation comes after treating a man who suffered from migraines for 12 years and had tried medication, yoga and avoiding potential ‘trigger foods’ to no avail.

Over 1 billion people worldwide have migraines, characterised as one-sided, pulsating headaches lasting 4–72 hours, and often accompanied by sensitivity to noise and light and sometimes prodromal auras. While the condition may be treated and prevented with drugs, a growing body of evidence suggests that diet can be an effective treatment.

Six months before his clinic referral, the man’s migraines had become chronic, occurring on 18–24 days of every month. The pain was described as starting suddenly and intensely in the forehead and left temple. The pain was throbbing in nature, usually lasting 72 hours. His headaches were accompanied by sensitivity to light and sound, and nausea and vomiting. On a scale of 0–10, he scored the pain severity as 10–12 out of 10.

Blood tests showed little systemic inflammation and a normal level of beta-carotene (53 µg/dL). This is likely due to his daily sweet potato consumption, which, although high in beta-carotene, are relatively low in the nutrients responsible for the anti-inflammatory and antioxidant properties of carotenoids, the authors pointed out. These are instead found in dark green leafy vegetables, such as spinach. Systemic inflammation and oxidative stress are implicated in migraine.

The authors recommended that he follow the Low Inflammatory Foods Everyday (LIFE) diet, which is a nutrient dense, whole food, plant-based diet.

The LIFE diet includes eating at least five ounces (142g) of dark green leafy vegetables every day, drinking one 32-ounce (905g) daily green LIFE smoothie, and cutting back on whole grains, starchy vegetables, oils, and animal protein, particularly dairy and red meat.

After two months on the LIFE diet, the frequency of his migraine attacks had fallen to just 1 day a month; the length and severity of the attacks had also lessened. Blood tests showed a substantial rise in beta-carotene levels, from 53 µg/dL to 92 µg/dL.

He stopped his migraine meds and even when he tried certain ‘challenge’ foods which triggered headaches, they were less intense. At three months his migraines completely stopped, and they haven’t returned in 7.5 years.
The 60-year-old patient, whose identity was not disclosed, said: “Before I changed my diet, I was suffering six to eight debilitating migraines a month, each lasting up to 72 hours. Most days, I was either having a migraine or recovering from one.”

The man was allergic, which studies suggest contributes to migraines, and his allergies had disappeared. He was also HIV positive, also linked to migraine risk, so it is certainly possible that the man’s HIV status and antiretroviral drugs had contributed to his symptoms, the reports acknowledge, which they could not exclude.
Nevertheless they concluded: “This report suggests that a whole food plant-based diet may offer a safe, effective and permanent treatment for reversing chronic migraine.

“While this report describes one very adherent patient who had a remarkable response, the LIFE diet has reduced migraine frequency within three months in several additional patients (personal communication).”

Source: EurekAlert!

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Ultra-thin Microelectrodes to Combat Severe Pain

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First author Matilda Forni with the ultra-thin microelectrodes during production (Photo: Agata Garpenlind)

In an entirely new stimulation method to combat severe pain, researchers at Lund University in Sweden have developed ultra-thin microelectrodes which are inserted into the pain centres of the brain.

This approach, which was tested in rats, provides effective and personalised analgesia, without the side effects of drugs. The findings were reported in Science Advances.

The quality of life of patients experiencing pain is greatly impacted by the lack of side-effect free treatment, and pain also impacts society in terms of reduced productivity. Side effects of pain medication can include reduced mental capacity and, in some cases, addiction. According to a recent American report, about 8% of the American population suffer from high-impact chronic pain.

To address this, professor of neurophysiology Jens Schouenborg led a research team which developed a method to combat pain via personalised stimulation using ultra-thin, tissue-friendly microelectrodes.

“The electrodes are very soft and extremely gentle on the brain. They are used to specifically activate the brain’s pain control centres without simultaneously activating the nerve cell circuits that produce side effects. The method involves implanting a cluster of the ultra-thin electrodes and then selecting a sub-group of the electrodes that provide pure pain relief, but no side effects. This procedure enables extremely precise and personalised stimulation treatment that was shown to work for every individual,” explained Prof Schouenborg.

Pain control is achieved by activating the brain’s pain control centres, these in turn block only the signal transfer in the pain pathways to the cerebral cortex.

“We have achieved an almost total blockade of pain without affecting any other sensory system or motor skill, which is a major breakthrough in pain research. Our results show that it is actually possible to develop powerful and side effect-free pain relief, something that has been a major challenge up to now,” explained first author and doctoral student Matilde Forni.

Over several years, the researchers developed a tissue-friendly, gelatine-based technology and surgical techniques that allowed them to precisely implant the flexible microelectrodes. According to the researchers, the new technique should work on all sorts of pain that are conveyed by the spinal cord, which is most types of pain.

“In our study we also compared our method with morphine, which was shown to deliver considerably less pain relief. In addition, of course, morphine has a powerful sedative effect as well as other cognitive effects. In the study we could also show that pain after sensitisation (hyperalgesia), which is common in chronic pain, was blocked”, said Prof Schouenborg.

The researchers plan to test the technology in humans and that within five to eight years yield an effective pain treatment, for pain from cancer or chronic pain in connection with spinal cord injuries, for which there is no currently satisfactory pain treatment..

The researchers also consider that the method could be used in a broader way to treat conditions besides pain.

“In principle, the method can be tailored to all parts of the brain, so we believe that it could also be used in the treatment of degenerative brain diseases such as Parkinson’s disease as well as in depression, epilepsy and probably stroke as well. The electrode technique also has applications in diagnostics and not least in research on how the mysterious brain works,” said Prof Schouenborg.

Source: Lund University