What Is Pain? What Causes Pain?

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy of MedicalNewsToday.com

Written by Christian Nordqvist

The English word ‘pain’ probably comes from Old French (peine), Latin (poena – meaning punishment pain), or Ancient Greek (poine – a word more related to penalty), or a combination of all three.

In medicine pain relates to a sensation that hurts. If you feel pain it hurts, you feel discomfort, distress and perhaps agony, depending on the severity of it. Pain can be steady and constant, in which case it may be an ache. It might be a throbbing pain – a pulsating pain. The pain could have a pinching sensation, or a stabbing one.

Only the person who is experiencing the pain can describe it properly. Pain is a very individual experience.

Types of pain

Acute pain – this can be intense and short-lived, in which case we call it acute pain. Acute pain may be an indication of an injury. When the injury heals the pain usually goes away.

Chronic pain – this sensation lasts much longer than acute pain. Chronic pain can be mild or intense (severe).

How do we classify pain?

Pain can be nociceptive, non-nociveptive, somatic, visceral, neuropathic, or sympathetic. Look at the details below.

Pain

Nociceptive: Somatic – Visceral: Non-Nociceptive: Neuropathic – Sympathetic

Nociceptive Pain – specific pain receptors are stimulated. These receptors sense temperature (hot/cold), vibration, stretch, and chemicals released from damaged cells.

Somatic Pain – a type of nociceptive pain. Pain felt on the skin, muscle, joints, bones and ligaments is called somatic pain. The term musculo-skeletal pain means somatic pain. The pain receptors are sensitive to temperature (hot/cold), vibration, and stretch (in the muscles). They are also sensitive to inflammation, as would happen if you cut yourself, sprain something that causes tissue damage. Pain as a result of lack of oxygen, as in ischemic muscle cramps, are a type of nociceptive pain. Somatic pain is generally sharp and well localized – if you touch it or move the affected area the pain will worsen.

Visceral Pain – a type of nociceptive pain. It is felt in the internal organs and main body cavities. The cavities are divided into the thorax (lungs and heart), abdomen (bowels, spleen, liver and kidneys), and the pelvis (ovaries, bladder, and the womb). The pain receptors – nociceptors – sense inflammation, stretch and ischemia (oxygen starvation).

Visceral pain is more difficult to localize than somatic pain. The sensation is more likely to be a vague deep ache. Colicky and cramping sensations are generally types of visceral pain. Visceral pain commonly refers to some type of back pain – pelvic pain generally refers to the lower back, abdominal pain to the mid-back, and thoracic pain to the upper back (see below for the meaning of referred pain).

Nerve Pain or Neuropathic Pain

Nerve pain is also known as neuropathic pain. It is a type of non-nociceptive pain. It comes from within the nervous system itself. People often refer to it as pinched nerve, or trapped nerve. The pain can originate from the nerves between the tissues and the spinal cord (peripheral nervous system) and the nerves between the spinal cord and the brain (central nervous system, or CNS).

Neuropathic pain can be caused by nerve degeneration, as might be the case in a stroke, multiple-sclerosis, or oxygen starvation. It could be due to a trapped nerve, meaning there is pressure on the nerve. A torn or slipped disc will cause nerve inflammation, which will trigger neuropathic pain. Nerve infection, such as shingles, can also cause neuropathic pain.

Pain that comes from the nervous system is called non-nociceptive because there are no specific pain receptors. Nociceptive in this text means responding to pain. When a nerve is injured it becomes unstable and its signaling system becomes muddled and haphazard. The brain interprets these abnormal signals as pain. This randomness can also cause other sensations, such as numbness, pins and needles, tingling, and hypersensitivity to temperature, vibration and touch. The pain can sometimes be unpredictable because of this.

Sympathetic Pain

The sympathetic nervous system controls our blood flow to our skin and muscles, perspiration (sweating) by the skin, and how quickly the peripheral nervous system works.

Sympathetic pain occurs generally after a fracture or a soft tissue injury of the limbs. This pain is non-nociceptive – there are no specific pain receptors. As with neuropathic pain, the nerve is injured, becomes unstable and fires off random, chaotic, abnormal signals to the brain, which interprets them as pain.

Generally with this kind of pain the skin and the area around the injury become extremely sensitive. The pain often becomes so intense that the sufferer daren’t use the affected arm or leg. Lack of limb use after a time can cause other problems, such as muscle wasting, osteoporosis, and stiffness in the joints.

What is referred pain?

Also known as reflective pain. When pain is felt either next to, or at a distance from the origin of an injury it is called referred pain. For example, when a person has a heart attack, even though the affected area is the heart, the pain is sometimes felt around the shoulders, back and neck, rather than in the chest. We have known about referred pain for centuries, but we still do not know its origins and what causes it.

How do you measure pain?

It is virtually impossible to measure a person’s pain objectively. Most experts say that the best way to find out how much pain a person is enduring is by a subjective pain report. A comprehensive assessment of pain should include:

* The identification of all the pains.

* This must include the most important ones.

* The site, quality, and radiation of pain

* What factors aggravate and relieve the pain


* When the pain occurs throughout the day


* What impact the pain has on the person’s function


* What impact the pain has on the person’s mood


* The sufferers’ understanding of their pain

There are many different methods for measuring pain and its severity. Health care professionals say it is important to stick to whatever system or tool you chose for a specific patient all the way through. If a patient is unable to report his pain, such as an infant, or a person with dementia, there are a number of observational pain measures a doctor can use.

Here is a list of some pain measures used today:

* Numerical Rating Scales

* The patient is given a form which asks him to tick from 0 to 10 what his level of pain is. 0 is no pain, 5 is moderate pain, and 10 is the worst pain imaginable.

* Please rate the pain you have right now
0 2 3 4 5 6 7 8 9 10
No pain Moderate pain Worst pain imaginable

The Numerical Rating Scales are useful if you want to measure any changes in pain, as well as gauging the patient’s response to pain treatment. If the patient has dyslexia, autism, or is very elderly and has dementia this may not be the best tool (see the ones below).

Verbal Descriptor Scale

This type of scale exists in many different forms. The patient is asked questions and responds verbally choosing from such terms as mild, moderate, severe, no pain, mild pain, discomforting, distressing, horrible, and excruciating.

Elderly patients with cognitive impairment, very young children, and people who respond better to verbal stimuli tend to have better completion rates with this type of scale, compared to the written numerical scale. Children respond even better to the faces scale (description below).

Faces Scale

The patient sees a series of faces. The first one is calm and happy, the second less so, etc., and the final one has an expression of extreme pain. This scale is used mainly for children, but can also be used with elderly patients with cognitive impairment. Patients with autism may respond better to this type of approach – people with autism tend to respond to visual stimuli well.

Brief Pain Inventory

This is a much more comprehensive written questionnaire. Not only does it gauge current level of pain, but also records the peaks and troughs of pain during previous days, how pain has affected mood, activity, sleep patterns, and how the pain may have affected the patient’s interpersonal relationship. The questionnaire also has diagrams which the patient shades – the shaded parts being where the pain is located and where it is most severe.

McGill Pain Questionnaire

This questionnaire measures the intensity (severity) of the pain, the quality of the pain, mood, and understanding of the pain. It is also known as the McGill Pain Index. It is a scale of rating pain developed at McGill University by Melzack and Torgerson (1971).

Look at the 20 groups below.

Circle one word in each group that best describes your pain.
Circle only three words from Groups 1 to 10 that best describe your pain response.
Choose just two words in Groups 11 to 15 that best describe your pain.
Just pick the one in Group 16.
Finally, choose just one word from Groups 17-20.
You should now have seven words. Those seven words should be taken to your doctor. They will help describe both the quality and intensity of your pain

Group 1 – Flickering, Pulsing, Quivering, Throbbing, Beating, Pounding
Group 2 – Jumping, Flashing, Shooting
Group 3 – Pricking, Boring, Drilling, Stabbing
Group 4 – Sharp, Gritting, Lacerating
Group 5 – Pinching, Pressing, Gnawing, Cramping, Crushing
Group 6 – Tugging, Pulling, Wrenching
Group 7 – Hot, Burning, Scalding, Searing
Group 8 – Tingling, Itching, Smarting, Stinging
Group 9 – Dull, Sore, Hurting, Aching, Heavy
Group 10 – Tender, Taunt, Rasping, Splitting
Group 11 – Tiring, Exhausting
Group 12 – Sickening, Suffocating
Group 13 – Fearful, Frightful, Terrifying
Group 14 – Punishing, Grueling, Cruel, Vicious, Killing
Group 15 – Wretched, Binding
Group 16 – Annoying, Troublesome, Miserable, Intense, Unbearable
Group 17 – Spreading, Radiating, Penetrating, Piercing
Group 18 – Tight, Numb, Squeezing, Drawing, Tearing
Group 19 – Cool, Cold, Freezing
Group 20 – Nagging, Nauseating, Agonizing, Dreadful, Torturing

Measuring pain when the patient is cognitively impaired

In this case doctors say that the patient’s subjective pain report is the most effective and accurate way of evaluating pain. If the severely cognitively impaired patient is observed carefully it is possible to pick out clues as to the presence of pain, e.g. restlessness, crying, moaning, groaning, grimacing, resistance to care, reduced social interactions, increased wandering, not eating, and sleeping problems.
What are the treatments for pain?

An underlying disorder, if treated effectively, will also get rid of the pain, or at least reduce it. If you have an infection and take antibiotics, the antibiotics may get rid of that infection, resulting also in the elimination of pain. Even if an underlying problem can be treated, you may still need analgesics (pain relievers).

Analgesics are good at relieving nociceptive pain, but not neuropathic pain. Chronic pain – long-lasting pain – may need other non-drug treatments as well.

Opioid Analgesics

Opioid analgesics are also known as narcotics. These are the strongest painkillers and are commonly used after surgery, for cancer, broken bones, burns, and various other situations. Even though opioids are not commonly used to treat non-cancer pain, their usage for non-cancer pain is becoming more widespread and acceptable. Some patients do not respond well to opioids and should not take them.

The patient will be given opioids in gradually increasing dosages. The ideal dose is reached when the pain is relieved and the side-effects are tolerable (increase any higher and the side effects become too much for the patient). Dosages should be generally much lower for older patients and infants.

The patient is administered opioids every few hours – each dose coinciding with the moment just before the pain starts becoming severe. Some patients are given higher dosages if the pain becomes more intense, while others are given other medications alongside the opioid. Pain can become more intense if the patient needs to move about, or if a wound dressing needs to be changed.

The dosage goes down if the pain intensity drops, until if possible, the doctor switches to a non-opioid analgesic.

People with kidney failure, liver problems, COPD (chronic obstructive pulmonary disease, dementia, tend to have more side effects when given opioids. The most common opioid side effects are drowsiness, constipation, nausea, vomiting, and itching. Generally, the side effects lessen as after time. Taking too much opioid can be dangerous. Patients who take opioids for long period become physically dependent and will have withdrawal symptoms when treatment is stopped – it is important that their dosage is tapered off gradually.

Nonopioid Analgesics

Nonopioid analgesics are used generally for mild to moderate pain. They are not addictive and their pain-relieving effects do not dwindle over time.

NSAIDs (nonsteroidal anti-inflammatory drugs)

These may be obtained either OTC (over-the-counter) or as a prescription medication, it depends on the dosage. Low dosage NSAIDs are effective for headaches, muscle aches, fever, and minor pains. At a higher dose they help reduce joint inflammation. There are three main types of NSAIDs, and they all block prostaglandins – hormone-like substances that cause pain, inflammation, muscle cramps, and fever.



Traditional NSAIDs – the largest subset of NSAIDs. As is the case with most drugs, they do carry a risk of side-effects, such as stomach upset and gastrointestinal bleeding. The risk of side effects is significantly higher if the patient is over 60. At higher doses, they should only be taken when monitored by a doctor.




COX-2 inhibitors – these also reduce pain and inflammation. However, they are designed to have fewer stomach and gastrointestinal side-effects. In 22004/2005 Vioxx and Bextra were withdrawn from the market after major studies showed Vioxx carried increased cardiovascular risks, while Bextra triggered serious skin reactions. Some other COX-2 inhibitors are also being investigated for side-effects. The FDA told makers of NSAIDs to highlight warnings on their labels in a black box.




Salicylates – these include aspirin which continues to be a popular medication for many doctors and patients. If your plan to take aspirin more than just occasionally you should consult your doctor. Long term high dosage usage of aspirin carries with it a significant risk of serious undesirable side effects, such as kidney problems and gastrointestinal bleeding. For effective control of arthritis pain and inflammation frequent large doses are needed. Nonacetylated salicylate is designed to have fewer side effects than aspirin. Some doctors may prescribe nonacetylated salicylate if they feel aspirin is too risky for their patient. Nonacetylated salicylate does not have the chemical aspirin has which protects against cardiovascular disease. Some doctors prescribe low dose aspirin along with nonacetylated salicylate for patients who they feel need cardiovascular protection.

View drug information on
Bextra – http://www.medilexicon.com/drugs/bextra.php
Vioxx – http://www.medilexicon.com/drugs/vioxx.php

Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

(http://www.medicalnewstoday.com/articles/145750.php)

FDA Requires Additional Labelling for Over-the-Counter Pain Relievers and Fever Reducers to Help Consumers Use Products Safely

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy FDA US Food and Drugs Administration – For Immediate Release

The Food and Drug Administration issued a final rule today that requires manufacturers of over-the-counter (OTC) pain relievers and fever reducers to revise their labelling to include warnings about potential safety risks, such as internal bleeding and liver damage, associated with the use of these popular drugs.

Products covered by the FDA action include acetaminophen, and a class of drugs known as the nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include aspirin, ibuprofen, naproxen, and ketoprofen. Acetaminophen is in a class by itself. The revised labeling applies to all OTC pain relievers and fever reducers, including those that contain one of these ingredients in combination with other ingredients, such as in cold medicines containing pain relievers or fever reducers.

“Acetaminophen and NSAIDs are commonly used drugs for both children and adults because they are effective in reducing fevers and relieving minor aches and pain, such as headaches and muscle aches, “ said Charles Ganley, M.D., director, FDA’s Office of Nonprescription Drugs in the Center for Drug Evaluation and Research.

“However, the risks associated with their use, need to be clearly identified on the label so that consumers taking these drugs are fully aware of the potential harm they can cause. It is important that they know how to take these medications safely to reduce their risk.”

Under the final rule, manufacturers must ensure that the active ingredients of these drugs are prominently displayed on the drug labels on both the packages and bottles. The labeling also must warn of the risks of stomach bleeding for NSAIDs and severe liver damage for acetaminophen.

Since 2006, some manufacturers have voluntarily revised their product labeling to identify these potential safety concerns. However, the voluntary changes to labelling do not address all of the labelling requirements in the new rule. For example, the new rule includes a warning on products containing acetaminophen that instructs consumers to ask a doctor before they are taking the blood thinning drug warfarin. The new rule requires all manufacturers to relabel their products within one year of April 28 2009.

Safety data reported in medical literature indicate that people sometimes take more acetaminophen than the labeling recommends. Others unknowingly take multiple products containing acetaminophen at the same time. Exceeding the recommended dosage of acetaminophen may increase the risks for severe liver damage. Alcohol use can also increase the risk of liver damage with acetaminophen.

The risk for stomach bleeding may increase in people who use NSAIDs and who are taking blood-thinning drugs (anticoagulants) or steroids. Stomach bleeding risks also increase for people who take multiple NSAIDs at the same time, or in people who take them longer than directed. Alcohol use can increase the risk for stomach bleeding with NSAIDs use.

An FDA Advisory Committee meeting will be convened on June 29 & 30, 2009, to discuss further steps the FDA could take to reduce the risk of liver damage associated with acetaminophen overdoses.

Source: FDA
OTC Pain Relievers – Acetaminophen: Tylenol & other Brands
NSAIDS – Aspirin: Bayer & other brands, Ibuprofen: Advil, Motrin & other brands. Naproxen: Aleve & other brands.

To read the final rule on the relabeling of OTC pain relievers and fever reducers, go to

http://edocket.access.gpo.gov/2009/pdf/E9-9684.pdf

To read the FR Notice announcing the FDA Advisory Committee meeting, see link below:

http://www.fda.gov/OHRMS/DOCKETS/98fr/E9-9380.pdf

Consumer Inquiries: 888-INFO-FDA

(http://www.fda.gov/bbs/topics/NEWS/2009/NEW02004.html)

Researchers probe kidney damage, protection in lupus

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy utsouthwestern.edu

by Aline McKenzie – 214-648-3404 – aline.mckenzie@utsouthwestern.edu

DALLAS – April 21, 2009

UT Southwestern Medical Center researchers probe kidney damage, protection in lupus. Kidney damage associated with the autoimmune disease lupus is linked to a malfunction of immune cells that causes them to congregate in and attack the organs, researchers at UT Southwestern Medical Center have discovered in a mouse study.

In a separate study with an international team, the researchers also found that a certain set of genes appears to protect the kidneys from a different sort of immune attack in both mice and humans.

“These studies, taken together, uncover two important molecules that underlie the pathology of lupus, particularly kidney disease,” said Dr. Edward Wakeland, chairman of immunology at UT Southwestern and co-senior author of the studies.

“In addition, they highlight a certain molecule as a potential target for treating this disease,” he said.

In the first study, which appears in the April issue of The Journal of Immunology, the researchers examined several strains of mice that mimic human lupus. They found that immune cells in those mice overproduced a particular molecule called CXCR4. In fact, the mice had up to twice as much CXCR4 as their normal counterparts in several types of immune cells. The lupus-prone mice also had more immune-system cells in their kidneys, indicating that the inflammatory action of the immune cells might be causing the kidney damage.

The CXCR4 molecule was already known to play a role in creating various types of blood cells and also has been shown to be active in cancer and AIDS. Cells with CXCR4 on their surface are attracted to another molecule released by cells in various organs, so they migrate toward those organs, including the kidney.

When the researchers treated the lupus mice with a substance that blocks CXCR4, the symptoms of lupus significantly diminished; many symptoms of kidney failure were averted; and the mice lived longer. The increased lifespan was greater when treatment began at an early age.

“This study indicates that drugs acting against CXCR4 might become useful therapies,” said Dr. Chandra Mohan, professor of internal medicine and co-senior author of the studies.

In the second study, published in the April issue of The Journal of Clinical Investigation, the researchers found that some members of a family of genes called kallikreins offered a degree of protection in both mice and humans against a type of kidney damage caused by a different mechanism.

For this mouse study, the researchers administered antibodies that attack a part of the kidney called the glomerular basement membrane, the portion of the organ that performs its main function of filtering wastes from blood. They then looked for genes that turned on or off in response to the antibody assault.

Nine forms of the kallikrein, or klk, gene became more active, resulting in a two- to sixfold increase in the proteins encoded by the genes in normal mouse strains, compared with lupus-prone strains. When some mice were given substances that block the action of kallikrein proteins, they showed more severe symptoms of lupus, suggesting that kallikreins protect against renal disease.

The researchers also studied 340 German patients with systemic lupus, matched with 400 healthy control subjects. The patients with lupus and kidney damage had klk genes that were different from those in the healthy patients. Similar findings were noted in a larger, more varied group of patients from Europe, the United States and Korea.

“All humans have Klk genes, but our findings show that some of us have a particular version that increases our risk for systemic lupus,” Dr. Wakeland said.

Future research will examine the mechanisms by which CXCR4 and klk genes might be aberrantly regulated in lupus and how they could be therapeutically targeted in human lupus, the researchers said.

Other UT Southwestern researchers involved in the first study were lead author and graduate student Andrew Wang; Dr. Anna-Marie Fairhurst, assistant instructor of immunology; Dr. Katalin Tus, instructor of immunology; former graduate student Srividya Subramanian; Dr. Yang Liu, postdoctoral researcher in internal medicine; Dr. Fangming Li, assistant professor of pediatrics; Dr. Peter Igarashi, professor of internal medicine; and Dr. Xin Zhou, professor of pathology. Researchers from the Université Paris-Descartes and Chemokine Therapeutics, Canada, also participated.
The study was funded by the National Institutes of Health.

Other UT Southwestern researchers involved in the second study were lead co-authors Dr. Kui Liu, instructor of internal medicine, and Dr. Quan-Zhen Li, assistant professor of immunology; Li Li, research associate in internal medicine; Jinchun Zhou, research scientist in immunology; Mei Yan, research associate in internal medicine; Dr. Qiu Ye, former postdoctoral fellow in immunology; Shengxi Liu, senior research associate in immunology; Dr. Chun Xie, former instructor in internal medicine; and Drs. Zhou and Liu.

Researchers from Oklahoma Medical Research Foundation; University of California, San Franciso; Long Island Jewish Health System, Manhasset; Medical University of South Carolina; and University of Alabama at Birmingham also participated, as did researchers from institutes in Sweden, Spain, Argentina, Germany, South Korea, Italy and the United Kingdom.

The study was funded in part by the Alliance for Lupus Research and the National Institutes of Health.
Visit http://www.utsouthwestern.org/rheumatology to learn more about clinical services in rheumatology at UT Southwestern. Visit http://www.utsouthwestern.org/dermatology to learn more about UT Southwestern’s clinical services in dermatology, including autoimmune diseases.

(http://www.utsouthwestern.edu/home/news/index.html)

FOR MORE STORIES ON HEALTH SEE http://jeannehambleton77.wordpress.com

Minister calls for pain indicators in QOF (Quality

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy of PulseToday.com

By Nigel Praities -21 Apr 09

A Government minister has invited applications for new pain management indicators for the QOF in a parliamentary debate held yesterday.

Health minster Ann Keen said the inclusion of pain in the QOF was a ‘key issue’ and that she hoped organisations would submit proposed indicators for the next review.

The debate was proposed by Anne Begg MP, the chair of the recently formed All-Party Parliamentary Group on Chronic Pain, who said pain should be considered as a ‘vital sign’ for PCTs and incentivised through the QOF.

‘The inclusion of pain assessment in the QOF would strongly encourage health professionals to be proactive and to ask a patient about their pain, treat it promptly and reassess it to ensure that the treatment given is effective, rather than expecting the patient to raise it first,’ she said.

Ms Begg also criticised the complete withdrawal of co-proxamol by the MHRA, and quoted figures revealed in Pulse earlier this year that showed an increase in morphine and tramadol prescriptions as a result of the withdrawal.

In response, Ann Keen said Ms Begg had made a ‘persuasive and eloquent case’ for pain indicators in the QOF and she hoped pressure groups, such as the Chronic Pain Policy Coalition – would press for its inclusion.

‘I understand that the next opportunity to submit suggestions for new indicators to NICE will be this summer. I hope that the chronic pain policy coalition will take the opportunity to suggest specific indicators at that stage,’ she said.

A spokesperson from the Chronic Pain Policy Coalition confirmed it would submit a proposal for new QOF indicators for the routine management and assessment of pain to NICE later this year.

‘Given the important role GPs have to play in the early identification, diagnosis and management of patients with pain, we strongly believe that this is an area in which greater incentivisation through inclusion within the QOF indicators would have a considerable positive impact,’ he said.

(http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4122478&c=2&cid=pain042209#)

IN THE HOUSE OF COMMONS 20 April 09 (Hansard source/TheyWorkForYou.com)

In the House of Commons on April 20 MP Anne Begg spoke about the Pain Management Services (England) as reported by Hansard and TheyWorkForYou.com

She said, “In the United Kingdom, 7.8 million people live with pain, day in and day out; that is the equivalent of about one in seven people in every single parliamentary constituency. I have asked for this debate in order to draw attention both to their problems and, more importantly, to some solutions that would not only improve the quality of life of so many of our constituents, but also reduce public expenditure on health, social care and incapacity benefits.

“If anyone is wondering why I, as a Scottish MP, am raising the issue of pain management services in England when health is a devolved issue, it is because I am the chairman of the recently set up all-party group on chronic pain. I suppose I should also declare an interest: I am one of the 7.8 million people in the UK who live with chronic pain.

“There could not be a better opportunity to consider the problem and suggest solutions. People in pain and the health professionals helping them have been pushing at a closed door for many years now. They have argued for early recognition of the needs of people in pain, early access to expert advice and treatment, and referral to a specialist pain clinic when necessary. That door was closed until recently; suddenly, it looks as though it is opening, and I am grateful to the chief medical officer for beginning that process.

MAJOR INITIATIVE

“His latest annual report, only just published, includes a chapter called “Pain: breaking through the barrier”. Sir Liam Donaldson looks at the issue of people living with pain in a sensitive and comprehensive way, and concludes with this statement:’A major initiative to widen access to high-quality pain services would improve the lives of millions of people.’ “

Ms Begg also said, “The evidence suggests that although pain services do exist in most secondary care NHS trusts, they are patchy, and variable in their resources and in the services that they provide. Crucially, the CMO’s report makes this point: each year, more than 5 million people in the United Kingdom develop chronic pain, but only two thirds will recover. Clearly, much more needs to be done to improve outcomes for patients. He reminds us that pain affects 7.8 million people, and that more than a third of households have someone in pain at any given time. Those figures are rising. Indeed, recent surveys suggest that chronic pain is more common now than it was 40 years ago.
Pain is becoming more common, but the effect that it has on individual lives is immense.

“The CMO highlights the fact that pain has a major impact on people’s lives, causing sleeplessness and depression, and interfering with normal physical and social functioning. That often leads to unemployment. He points out how it affects all age groups. Perhaps most worryingly, he states that 8 per cent. of children experience severe pain, that back pain alone costs the economy £12.3 billion per year and that early intervention may prevent pain from becoming persistent. In fact, it has been shown that the cost of chronic pain is greater than that of heart disease or diabetes.

“Looking at the limited number of specialist pain clinics, the CMO points out that systems and infrastructure do not meet need or demand, and that better co-ordination of services, and services designed around patients’ needs, are essential. Pain needs to be considered in its own right, because it is often the pain that dominates the patient’s life, not the illness or condition that causes the pain.

As one patient has said: ‘At first I presumed the pain would eventually go away and I would get better. I didn’t expect to develop chronic pain, or that it would stop me working and lead me to consider suicide. I just want my life back.’

Another said: ‘I am in constant and debilitating pain, often unable to do even the most simple activity such as making myself a cup of tea. I have daily bad headaches, and have no quality of life. It is making me very depressed and life is hell.’

Clearly, we have a duty to ensure that the individual has access to the right treatment as early as possible. That treatment has to come from a properly trained professional, and a multidisciplinary team if needed.

“I was surprised by the amount of interest that this debate has generated. I have been contacted by a number of organisations wishing me to raise their concerns. Age Concern and Help the Aged have particular issues relating to the elderly.

AGEING PROCESS

“They say that pain is not a normal part of the ageing process, and we should not accept it as such. We should challenge discrimination and ageist attitudes with regard to pain in older people. They say that constant pain can lead to a loss of dignity. Some 90 per cent. of calls to Arthritis Care’s helpline concern pain, most of them from people in severe pain. In the UK, pain crises account for 60 to 80 per cent. of emergency presentations in hospital admissions for sickle cell disorder.

CO-PROXAMOL WITHDRAWAL AND NAMED PATIENTS

“This is not the first time I have had an Adjournment debate on the issue of pain. Ever since the Government first indicated that they intended to withdraw the analgesic co-proxamol, I have been trying to persuade Ministers that it should not be completely withdrawn as a small group of people still has not been able to find an alternative and certainly not anything so effective. These are all people who suffer chronic pain, who are saying that only co-proxamol works not because they want to be awkward but because it allows them to carry on with their life.

“One person in that position has said: ‘With co-proxamol I had pain but it was bearable, now I can walk only a few steps before being forced to rest; before I managed to tend my flower garden, now I can only sit and feel depressed with pain and frustration’.

“I have several constituents who depended on co-proxamol but cannot now get access to it. While the Government say that co-proxamol is available on a named patient basis, that is of cold comfort to those whose GPs are refusing to prescribe the drug at all. GPs are not comfortable prescribing off licence as they do not always feel that they have the specialist knowledge. But consultants at pain clinics do.

“The main reason the Government gave for withdrawing co-proxamol was the suicide statistics. As it is now extremely difficult for even those who need the drug to access it, the incidence of suicide attributed to co-proxamol is now tiny. However, the use of stronger pain relief and particularly opiates has grown. A recent Pulse article says that there has been a 44 per cent. rise in prescriptions for morphine and a 61 per cent. rise in tramadol prescriptions. That cannot be good pain management, so I ask the Minister to look at this issue again.

“I have not, however, sought this debate to lay blame at the Government’s door on this matter: rather, I hope to encourage the Minister to consider the recommendations laid out in the chief medical officer’s report and to give due regard to their feasibility. I do not have time to discuss them all, but I do want to take this opportunity to bring some to the Minister’s attention.

PAIN TRAINING SHOULD BE EXTENDED

“First, training on chronic pain should be included in the curriculum for all health professionals who deal with patients. However, it is vital that this core training is extended to all health professionals, and in particular to GPs who, at the very least, should have pain training as part of their standard undergraduate education.

“Secondly, consideration should be given to the inclusion of the assessment of pain and its associated disability in the quality and outcomes framework—QOF—in primary care. That is an extremely important point, because the inclusion of pain assessment in the QOF would strongly encourage health professionals to be proactive and to ask a patient about their pain, treat it promptly and reassess it to ensure that the treatment given is effective, rather than expecting the patient to raise it first.

“A recent report on osteoarthritis found that 50 per cent. of people said that they would need to be in frequently unbearable pain before considering seeing their GP—clearly this is a significant barrier.

FIFTH VITAL SIGN – PAIN SCORE

“Another recommendation was that a pain score should become part of the vital signs monitored routinely in hospital. Indeed, the Chronic Pain Policy Coalition has been campaigning for some time now for pain to be adopted as the fifth vital sign. If implemented, this recommendation would ensure that health professionals become proactive in asking their patients about pain. People would recover faster and reduce the burden of care on others.

MODEL PAIN SERVICE OF PATHWAYS OF CARE

“The final recommendation I want to highlight relates to the development by experts of a model pain service of pathways of care with clear standards. The work could build on the excellent 18-week cross specialty chronic pain pathway developed by patients and clinicians that has been supported by the Department of Health.

“It is an important step forward and should be extended to ensure that all patients are offered comprehensive treatment options. That would improve rapid access and reduce the current variability in treatment that patients receive. Patients need to be confident that they can be offered effective options wherever they live.

“Commitments have already been made both in Scotland with the ‘Getting to GRIPS with Chronic Pain’ report and in Wales under the ‘Designed for Life’ programme to assess and improve the services available for patients with chronic pain. I hope I have shown the Minister that there are patients, third sector organisations such as Arthritis Care and health professionals in England anxious to get hold of these recommendations and take them forward. They will need encouragement and flexibility in the way in which integrated services are funded and in how outcomes are measured.

PAIN CHAMPION DEMANDED

“Above all, people in pain need a champion. Tsars such as Mike Richards for cancer and Roger Boyle for cardiology have shown how such champions can make a difference. Pain affects cancer patients and heart patients as well as millions of others with back pain, arthritis, pelvic pain and a multiplicity of conditions. Surely the numbers involved and the importance of early intervention demand a pain champion.

“I know that the concerns I have raised in this debate are shared by a number of my hon. Friends and indeed by many of their constituents. I thank the Minister for hearing me out, and I hope that she can give consideration to the points I have raised.

REPLY

Replying Ann Keen (Parliamentary Under-Secretary (Health Services), Department of Health; (Hansard source) congratulated Miss Begg on securing this Adjournment debate on a “most important topic, which Professor Sir Liam Donaldson chose to highlight recently in the 150th report of the chief medical officer.”

She said, “The report of the chief medical officer is an independent report to Government on aspects of the nation’s health and, as such, draws attention to a number of different major health challenges. In his annual report for 2008, the chief medical officer called for a major initiative to widen access to high-quality pain services to improve the lives of millions.

NATIONAL PAIN DATABASE

“I am delighted to inform my hon. Friend and the House that I received a letter from Professor Black, the chair of the advisory group, just before the Easter recess, and it recommended that the national pain database, run jointly by the Royal College of Anaesthetists and the British Pain Society, should be funded as part of the national clinical audit programme.”

EDITOR’S NOTE: On behalf of the fibromyalgia community living with chronic pain, numbering around two million, mainly women, me included, and those of us who survived thanks to co-proxamol, I would like to thank Anne Begg MP publicly for speaking out on our behalf.

Had I known Miss Begg was to initiate this debate I would, of course, have asked her to include fibromyalgia in her chronic pain list. Hopefully she will read this somewhere, sometime, and might think kindly of us when next raising chronic pain and co-proxamol.

For many of us co-proxamol, when it was £2.79 for 100 tablets, was an inexpensive painkiller. Had we known this it would have been cheaper than the prescription charge if we had been able to buy it. This was before the Government got involved. It was a life saver for those with fibromyalgia, and many others. In those days we had some relief…now it is pain 24/7 thanks those who meddled against the wishes of many doctors, consultants, a number of MPs and the patients. They did not give a jot about us at the ‘coal face’ living with pain for the rest of the life. Yes I have tried the alternatives and they disagreed with me and my IBS and gastric problems. They should have tightened the rules allowing those who really need it to be able to get it, prescribed without litigation problems.

Today albeit your GP knows you are in pain and you should be a named patient, after years of safely taking co-proxamol without a hint of any problems, he will not prescribe it due to the risk of litigation involved with prescribing an unlicensed drug. Mr. B. sitting comfy in his armchair (free of pain) with all found, at No.10, your Government has a lot to answer for…….. the loss of co-proxamol is most certainly one of them.

Letters to Anne Begg at begga@parliament.uk would I am sure be much appreciated by her especially if you make reference to her debate in the House of Common on 20 April 200 and give her more ammunition about your problems with co-proxamol and fibromyalgia. Maybe you will send a copy to me please -fmsglobalnews@me.com. Thanks.

For the background to the Co-proxamol debate and MP Anne Begg.
SEE: http://fmsglobalnews.wordpress.com/2009/03/13/co-proxamol-a-controlled-drug/

http://fmsglobalnews.wordpress.com/2009/03/24/prescriptions-for-opioids-jump-following-co-proxamol-ban/

http://jeannehambleton77.wordpress.com/2008/01/03/no-u-turn-on-co-proxamol-withdrawal/

http://jeannehambleton77.wordpress.com/2007/12/05/co-proxamol-bungled-withdrawal-is-a-farce/

http://jeannehambleton77.wordpress.com/2007/11/26/co-proxamol-withdrawal-debate/

SEE: http://jeannehambleton77.wordpress.com for more health stories

Enduring chronic stress can destroy brain cells

From the FMS Global News Desk of Jeanne Hambleton (UK)

COURTESY OF KELOWNA CAPITAL NEWS – bclocalnews.com

By Annie Hopper – Kelowna Capital News- April 18, 2009

Does stress damage the brain? Accumulative stress not only affects your ability to remember and learn but research scientists have now discovered that chronic stress actually damages and kills brain cells.

Eliminating sources of stress and finding ways to reverse and minimize the effects of stress is our number one health challenge.

Stress is much more than feeling uptight about life.

Unhealthy forms of stress can be emotional (consistent fear, anger or worrying), mental (obsessive thought patterns, negative self talk) or physical (like a car accident, accumulative chemical exposure, virus, infection or chronic pain).

Is it possible that these stressors are at the very root of many life ailments?

The answer here folks is an undeniable YES.

Accumulative stress, in all of its forms, can have a damaging effect on brain function and structure.

This results in faulty brain wiring that not only causes impaired brain function, but can also manifest as a variety of health challenges as well as a maladapted response to stress.

A surprising consequence to brain function as the result of stress is that it can impair the normal neuronal sensory input and the circuitry in the brain can become interrupted or cross-wired.

What this means is that the regular function for a specific part of the brain becomes impaired somehow. The degree of impairment is directly related to how the brain has “crossed its wires” so to speak.

In the case of chronic pain this can mean that the pain signals keep occurring despite lack of a trigger or tissue damage.

We literally get stuck in impaired brain pathways that “feel” real.

Travelling down this impaired pathway also triggers us to think in specific ways in order to protect the perceived injury.

Our thoughts become consumed with how we can avoid pain, and worrying about what might happen if we trigger the pain.

This “protective” thinking strengthens and reinforces this abnormal pathway.

This protective thinking can also set off a cascading effect of stress in the body that not only causes more pain, but can also set off a cascading effect in the body.

Chronic stress also effects immune system function.

The good news here is that the brain has the ability to change and heal itself.

This is known as neuroplasticity and it is the greatest breakthrough in neuroscience in the last four hundred years.

Through practiced mental and behavioural training we have the power to act back on the brain and alter the neuronal patterns that are at the root of many illnesses. And I am not just talking about learning how to meditate here, although meditation is always a valuable tool to have in your wellness tool kit.

I am talking about tools that will help you retrain your brain, transform your health and reclaim your life.

Tools that will assist you in creating your personal health makeover—both internally and externally.

On May 8 to 10, I will teach a three-day brain training workshop called the Dynamic Neural Retraining System at the Hotel Eldorado.

In this workshop, I will show you how to promote radical, positive neuroplastic changes in the brain and how to decrease the body and brain’s stress response.

I consider this workshop extremely valuable for people with Chronic Fatigue Syndrome, fibromyalgia, chronic pain syndromes, multiple chemical sensitivities, electro-magnetic sensitivities and a host of anxiety disorders.

Seating is limited to 10 participants.

Please contact me for more information or to register. Early bird registration is until April 27.

Annie Hopper is a Core Belief Counsellor in Kelowna. 250-862-1766. http://www.anniehopper.com

© Copyright Black Press. All rights reserved
(http://www.bclocalnews.com/lifestyles/43195802.html)

SEE: http://jeannehambleton77.wordpress.com for more health stories

Stanford develops imaging technique to catch arthritis early in onset

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy of Stanford School of Medicine USA

BY BRUCE GOLDMAN

STANFORD, Calif. — You come into a doctor’s office with severe knee pain. The physician orders an MRI, which reveals substantial loss of cartilage — osteoarthritis, that is—in your knee joint.

At this point, not much can be done beyond gulping down palliatives and trying to keep your weight off the joint. But the damage may have started building as much as 20 years earlier, possibly due to a traumatic injury to the affected joint.

Just ask Garry Gold, MD, an associate professor of radiology at the Stanford University School of Medicine. Now 45, Gold sustained a knee injury 20 years ago while playing in a pickup basketball game. These days, he is starting to wish his house, currently being remodeled, did not have any stairs.

Gold, who has been diagnosed with osteoarthritis, is working with an imaging technology called sodium MRI to diagnose osteoarthritis as long as decades before the onset of physical symptoms. That may spawn new therapies that could possibly have blocked his disease before it put an end to his basketball days.

Gold is collecting young athletes who have suffered damage to the anterior cruciate ligament, or ACL, in their knee—an injury afflicting several hundred thousand people annually in the United States alone. This knee insult is especially common among female athletes.

“A good fraction of the Stanford women’s basketball and soccer teams either have torn their ACL sometime in the past or will tear it while they are still at Stanford,” Gold said. Even when the initial ligament lesion is repaired surgically, victims remain at almost doubled risk for symptomatic osteoarthritis in the injured knee a decade or two down the road, compared with uninjured people.

MRI now in routine use works by pulsing the area to be observed with electromagnetic energy, at a frequency that preferentially excites the protons in water molecules. As the protons settle back to a relaxed state, they send out an electromagnetic burst of their own, which can be picked up by sensors in the apparatus. Because cartilage has lots of water compared with nearby bone, it shows up on a computer-generated image of the region.

But while standard MRI gives a reasonable display of overall cartilage structure, it does not tell a diagnostician much about the quality of that cartilage.

“If you look into a big house and you see that it is standing up,” Gold said, “you may assume it is going to be safe in the event of an earthquake. But without closer inspection, you do not know much about the integrity of the structure.”

If standard MRI is akin to a view of standing timber in the house, the version Gold is using, called sodium MRI, enables the visualization of dry rot infecting and weakening the wood.

A key structural material in cartilage, called glycosaminoglycan, occurs in a complex with sodium, an elemental metal that has its own set of excitation and relaxation frequencies and is more restricted to cartilage than water is.

Sodium MRI has been around for years, but until recently it could not be used in clinical settings. For one thing, the magnets employed to excite sodium atoms were too puny, making crisp resolution possible only with tiny creatures such as mice.

Gold and his colleague Brian Hargreaves, PhD, assistant professor of radiology, have designed improved magnets and software to scale up the technology for human application.

They are on the right track, said Ari Borthakur, a University of Pennsylvania scientist who is not involved in Gold’s research but has done pioneering work with sodium MRI since writing his PhD thesis on it some years ago.

“Everything his lab has developed is going to be applicable in the clinics,” said Borthakur. “As America ages, we are expecting to see a huge increase in osteoarthritis, and any technique that could be used for its early diagnosis, or that could help developing therapies for curing it, or even slowing the progression of cartilage loss, would be tremendous.”

Gold and Hargreaves’ project is being conducted with funding from the National Institutes of Health and GlaxoSmithKline, an international pharmaceutical company. Neither researcher owns stock in, or receives consulting fees from, the company.

Working with Hargreaves, Gold has imaged the knees of about a dozen volunteers who have suffered a recent ACL injury. In every case so far, significant losses of glycosaminoglycan can be glimpsed under sodium MRI scanning, despite the absence of any sign of damage to cartilage observed with standard MRI. Almost invariably, sodium MRI scans of the injured knee—but not of the other, uninjured one—reveal glycosaminoglycan deficits within three years of the injury, potentially enabling a vastly accelerated diagnosis.

This ought to speed the development of new therapies, and radically lower the cost of doing so, Gold said. The idea is to be able to use glycosaminoglycan loss as a “surrogate marker” of impending osteoarthritis, much as high LDL levels are used to flag people at risk of heart disease—perhaps years before actual symptoms of heart disease manifest. While not everybody with elevated LDL develops cardiovascular disease, this marker has been sufficiently predictive of that condition that regulatory authorities routinely approve drugs based on their ability to lower LDL.

Catching osteoarthritis during its stealth phase may spur clinical trials that would be prohibitively time-consuming and costly if standard MRI were employed, because of the huge lag from the time of an ACL injury until the time cartilage deterioration can be detected by that old method.

With sodium MRI, cohorts of treated vs. untreated at-risk patients could be imaged over time to see if, within a few years of the injury, a drug or a lifestyle change is reducing or arresting the loss of glycosaminoglycan from the ligament. Once promising drugs or lifestyle changes are identified, they could then be administered to at-risk patients long before symptoms surface, Gold said.

As for Gold himself, he has yet to see what his own damaged knee looks like under sodium MRI. The 6-foot-6 once-avid amateur basketball center’s knee is too big for even his improved new experimental apparatus to fit. It’s probably too late for any kind of imaging to do Gold much good now, anyway. He already knows he’s got arthritis. “I don’t even want to look,” he said.

The Stanford University School of Medicine consistently ranks among the nation’s top 10 medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://mednews.stanford.edu. The medical school is part of Stanford Medicine, which includes Stanford Hospital & Clinics and Lucile Packard Children’s Hospital. For information about all three, please visit http://stanfordmedicine.org/about/news.html.

(http://med.stanford.edu/news_releases/2009/january/sodium.html)

SEE: http://jeannehambleton77.wordpress.com for more health issue stories

Why You Must Protect Your Knees

From the FMS Global and UK News Desk of Jeanne Hambleton

Courtesy of WebMD – Feature from “Redbook” Magazine

By Jeannette Moninger

Women are the weaker-kneed sex – really! Ease the pain with these tips.

Years of stooping, kneeling, and running around really takes a toll on your knees, and women have it especially bad: Studies show we are up to six times more likely than men to suffer from knee injuries like ACL tears. Got an achy, creaky, or weak knee? We will help you find the cause — plus, we have got ways to fix your bad knees for good.

Creaky knees

Your knees pop, grind, and ache while climbing stairs or after prolonged sitting.

The cause: Though it is commonly called “runner’s knee,” patellofemoral syndrome afflicts even couch potatoes. The creaking you feel is a result of a misaligned kneecap grating over the lower end of your thighbone. Women are particularly susceptible to this syndrome because our naturally wide pelvises cause our thighs to slant inward, creating a wider quadriceps, or Q, angle than men have.

“This Q angle places extra force on a woman’s knees,” says Kathy Weber, M.D., director of women’s sports medicine at Rush University Medical Center in Chicago.

The fix: If you regularly do high-impact workouts such as running or playing tennis, cut back (but do not stop altogether or the muscles that support your knees will weaken) and add gentler activities such as swimming and yoga to your routine. Also, buy new workout shoes when your shoes’ soles are worn so that your arches and joints are adequately cushioned.

Achy knees

During physical activity, you feel a sharp pain between your kneecap and shinbone. The pain persists as a constant, dull ache.

The cause: tendonitis, which occurs when the tendons connecting your kneecap to the shinbone become inflamed due to repeated stress and overuse. Symptoms flare up when you increase the frequency or intensity of your workouts.

The fix: To ease pain and reduce swelling, take a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen, and ice, rest, and elevate your throbbing knee, especially following a workout. Also, ask your doctor about patellar tendon straps, Velcro bands placed just under your kneecap, which relieve pain by taking pressure off the tendon. If the pain persists or worsens, see your doctor.

Stiff knees

Your knee is swollen and puffy, and you have trouble straightening or bending it.

The cause: osteoarthritis. The cartilage that cushions your joints breaks down due to use, age, or excess weight, and makes your body produce more joint fluid in the knee. When the cartilage wears down completely, you are left with bone rubbing on bone and painfully swollen joints, says Tamara Martin, M.D., an orthopedic surgeon at Brigham and Women’s Hospital in Boston.

The fix: Losing just 11 pounds can take pressure off your knees and reduce arthritis pain by 50 percent, according to one study. In addition, taking NSAIDs, resting, and using ice can alleviate pain and swelling. If your knee becomes red or feels warm to the touch, see your doctor, who may drain the excess joint fluid with a needle. About 25 percent of people with osteoarthritis need knee-replacement surgery.

©2005-2009 WebMD, LLC. All rights reserved
(http://www.webmd.com/pain-management/knee-pain/features/why-you-must-protect-your-knees?ecd=wnl_art_040609)

Knee replacement surgery

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In knee replacement surgery, the ends of the damaged thigh and lower leg (shin) bones and usually the kneecap are capped with artificial surfaces lined with metal and plastic. Usually, doctors replace the entire surface at the ends of the thigh and lower leg bones. However, it is increasingly popular to replace just the inner knee surfaces or the outer knee surfaces, depending on the location of damage. This is called unicompartmental replacement. People who are good candidates for unicompartmental surgery have better results with this procedure than with total joint replacement. 1 Doctors usually secure knee joint components to the bones with cement.

In knee replacement surgery, doctors remove the damaged cartilage and replace it with new joint surfaces in a step-by-step process.

Joint changes caused by osteoarthritis may also stretch and damage the ligaments that connect the thighbone to the lower leg bone. After surgery, the artificial joint itself and the remaining ligaments around the joint usually provide enough stability so that the damaged ligaments are not a problem.

Doctors most often use regional anesthesia for joint replacement surgery. That means you cannot feel the area of the surgery and you are sleepy, but you are awake. The choice of anesthesia depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

What To Expect After Surgery – Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medications to control pain, and perhaps medications to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you do not feel well.

When you wake up from surgery, you will have a bandage on your knee and probably a drain to collect fluid and keep it from building up around your joint. You may have a catheter, which is a small tube connected to your bladder, so you do not have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots. Some surgeons recommend that you spend time in a continuous passive motion machine (CPM) to help keep your knee flexible. The machine has a cradle for your leg and is fitted to your leg length and joint position. The amount it bends your knee is adjustable. You may already have a CPM slowly bending and straightening your knee when you wake up after surgery.

Your health professional may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating.

The first few days

You will probably still be taking some medication. You will gradually take less and less pain medication. You may continue anticoagulant medications for several weeks after surgery.

Most people who have knee replacement surgery start to walk with a walker or crutches the day after surgery and can bear weight on the knee if it is comfortable.

A physical therapist will help you gently bend and straighten your knee. Your therapist will also begin some simple exercises to help strengthen your leg muscles.

Rehabilitation (rehab) after a knee replacement is intensive. The main goal of rehab is to allow you to bend your knee at least 90 degrees-enough to do daily activities, such as walking, climbing stairs, sitting in and getting up from chairs, and getting in and out of a car. Most people can get considerably more bending than 90 degrees after surgery. However, one of the factors that affects how much bend you get after surgery is how much bend you had before surgery. To get the most benefit from your surgery, it is very important that you take part in physical therapy both while you are in the hospital and after you go home from the hospital.

Most people go home within a few days to a week after surgery. Some people who need more extensive rehab or those who do not have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

Once you go home, monitor the surgery site and your general health. If you notice any redness or drainage from your wound, notify your surgeon. You may also be advised to take your temperature twice each day, and to let your surgeon know if you have a fever over 100.5F.

Rehabilitation generally continues after you go home from the hospital until you are able to function more independently and you have recovered as much strength and range of motion in your knee as you can. You will continue to work on increasing the amount you can bend your knee and on building strength and endurance. Total rehabilitation after surgery will take several months.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should also take a short walk several times each day. If you notice any soreness, try a cold pack on your knee and perhaps decrease your activity a bit, but do not stop completely. Sticking to your walking and exercise program will help speed your recovery.

Your doctor may recommend that you ride a stationary bicycle to strengthen your leg muscles and improve your knee bending. Swimming is also a good exercise after knee surgery, once your sutures or staples are removed and you are able to go in the water.

Living with a knee replacement

Your health professional may want to see you periodically for several months or more to monitor your knee replacement. Gradually, you will return to most of your presurgery activities.

Controlling your weight will help your new knee joint last longer.

Stay active to help maintain strength, flexibility, and endurance. Your activities might include walking, swimming (once your wound is completely healed), dancing, golf (do not wear shoes with spikes, and use a golf cart), and bicycling on a stationary bike or on level surfaces.

Your health professional may want you to take antibiotics before dental work or any invasive medical procedure for the rest of your life. This will help prevent infection around your knee replacement.

Why It Is Done

Doctors recommend joint replacement surgery when knee pain and loss of function become severe, and medications and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your knee to see whether they are damaged and to make sure that the pain is not coming from somewhere else.

Doctors may not recommend knee replacement for people who:

Have poor general health and may not tolerate anesthesia and surgery well.

Have an active infection or are at risk for infection.

Have osteoporosis (significant thinning of the bones).

Have severe weakness of the quadriceps muscles at the front of the thigh.

Have a knee that appears to bend backward when the knee is fully extended (genu recurvatum), if this condition is due to muscle weakness or paralysis.

Are severely overweight (replacement joints may be more likely to fail in people who are very overweight).

Some doctors will recommend other types of surgery if possible for younger people and especially for those who do strenuous work. A younger or more active person is more likely than an older or less active person to have an artificial knee joint wear out. People who are very overweight are also more likely to have an artificial knee joint wear out from the extra stress on the joint.

Doctors usually do not recommend knee replacement surgery for people who have very high expectations for how much they will be able to do with the artificial joint (for example, people who expect to be able to run, ski, or do other activities that stress the knee joint). The artificial knee allows a person to do ordinary daily activities with less pain. It does not restore the same level of function that the person had before the damage to the knee joint began.

How Well It Works

Most people have much less pain after knee replacement surgery and are able to do many of their daily activities more easily.

The knee will not bend as far as it did before you developed knee problems, but the surgery will allow you to stand and walk for longer periods without pain.

After surgery, you may be allowed to resume activities such as golfing, riding a bike, swimming, walking for exercise, dancing, and cross-country skiing (if you did these activities before surgery).

Your doctor may discourage you from running, playing tennis, squatting, and doing other things that put a lot of stress on the joint.

The younger you are when you have the surgery and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you are not overweight and you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint will probably last the rest of your life.

Risks

Risks from knee replacement surgery include:

Blood clots. People may develop a blood clot in a leg vein after knee joint replacement surgery. Blood clots can be dangerous if they block blood flow from the leg back to the heart or move to the lungs. Blood clots occur more commonly in older people, people who are very overweight, people who have had blood clots before, and those who have cancer.

Infection in the surgical wound or in the joint. Infection is rare in people who are otherwise healthy. Only about 1 to 4 out of 200 people develop an infection after knee replacement surgery. 2 People who have other health problems, such as diabetes, rheumatoid arthritis, or chronic liver disease, or those who are taking corticosteroids are at higher risk of infection after any surgery. Infections in the wound usually are treated with antibiotics. Infections deep in the joint may require more surgery, and in some cases the doctor must remove the artificial joint.

Nerve injury. In rare cases, a nerve may be injured around the site of the surgery. It is more common (but still unusual) if the surgeon is also correcting deformities in the joint. A nerve injury may cause tingling, numbness, or difficulty moving a muscle. These injuries usually get better over time and in some cases may go away completely.

Problems with wound healing. Wound healing problems are more common in people who take corticosteroids or who have diseases that affect the immune system, such as rheumatoid arthritis and diabetes.

Lack of good range of motion. How much you can bend your knee after surgery depends a lot on how much you could bend your knee before surgery. Some people are not able to bend their knee far enough to allow them to do their regular daily activities, even after several weeks of recovery. If this happens, the doctor may give you a medication to relax your muscles and then gently force your knee to bend further. This may loosen tissues around the joint that are preventing you from bending it.

Dislocation of the kneecap (patella). This is an uncommon complication of knee replacement surgery. If this happens, the kneecap may move to one side of the knee, and it will “pop” back when you bend your knee. This may not be painful, but it may make the knee feel unstable, and it may be uncomfortable. Dislocation of the kneecap interferes with the way your thigh muscles (quadriceps) work, and it usually needs to be treated with surgery. In some cases, the knee replacement surgery must be completely redone if the dislocation is caused by a problem with the way the components in the knee line up.

Fracture of the kneecap (patella). The kneecap could fracture either because of a fall or while you are using the knee normally. This complication is very uncommon. It may be seen in people who can bend the knee almost normally and can easily climb stairs and get up from chairs. Doctors usually can treat a fractured kneecap without surgery.

Instability in the joint. The knee may be unstable or wobbly if the replacement components are not properly aligned. You may need a second surgery to align the components correctly so that your knee is stable.

The usual risks of general anesthesia. Risks of any surgery are higher in people who have had a recent heart attack and those who have long-term (chronic) lung, liver, kidney, or heart disease.

What To Think About

Continued exercise (swimming, walking) is important to your general well-being and muscle strength. Discuss with your doctor what type of exercise is best for you.

You may donate your own blood to use during surgery if needed. This is called autologous blood donation. If you choose to do this, start the donation several weeks before the surgery so that you have time to donate enough blood and rebuild your blood volume before surgery.

If you need more than one joint replacement surgery, such as both knees or a knee and a hip, there are some general guidelines that may help you and your doctor decide in which order to do the surgeries.

Should I have knee replacement surgery? Guidelines for multiple joint replacements

Some people may need to have more than one joint replaced-for example, a shoulder and an elbow, a shoulder and a knee, both knees, or a hip and a knee. Doctors have different opinions about what is best, based on their experience and your specific situation. Your doctor will consider many factors, but the following are some general guidelines.

If you need both a shoulder and an elbow replaced, your doctor will probably replace the more painful and disabling joint first.

If you need a shoulder and either a hip or knee replaced, your doctor usually cannot replace the hip or knee until at least 3 months after the shoulder. This is to give the shoulder time to heal before you need to use crutches or a walker after the surgery on your hip or knee.

If you need both a hip and a knee replacement, and you are not sure how well you will tolerate rehabilitation (rehab), most doctors will recommend having surgery on the hip first. Recovery after hip surgery does not require as much rehab, so if you do well, you may also do well with the more intensive rehab required after knee surgery.1

If both knees or both hips need replacement, some doctors recommend doing both knees or hips at the same time during the same surgery. Others may recommend doing two separate surgeries during a single hospital stay.

If you need hip and knee replacement surgery on the same leg, doctors will usually replace either the most painful joint or the hip first. There are two reasons for this:2

Pain from arthritis in the hip joint can spread to the knee (referred pain). Replacing the hip first gives you a better idea how much of your knee pain is actually from arthritis in your knee.

The hip surgery usually is done first because a painful knee will not interfere too much with successful rehab after hip surgery. On the other hand, a painful hip may interfere with successful rehab after knee replacement surgery.

If you do have two surgeries at the same time or very close together, your recovery is likely to take longer than if you had a single surgery. However, it is still likely to be shorter than the total recovery time for one surgery and recovery followed by a separate surgery and recovery.

(http://www.webmd.com/hw-popup/guidelines-for-multiple-joint-replacements)

Citations
Sledge CB (2005). Principles of reconstructive surgery for arthritis: The knee. In ED Harris Jr et al., eds., Kelley’s Textbook of Rheumatology, 7th ed., vol. 2, pp. 1890–1900. Philadelphia: Elsevier Saunders.

Moore KD, Cuckler JM (2005). Surgical treatment of knee arthritis. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 1, pp. 1067–1076. Phildelphia: Lippincott Williams and Wilkins.

Author Robin Parks, MS – Editor Kathleen M. Ariss, MS – Associate Editor Pat Truman, MATC
Primary Medical Reviewer E. Gregory Thompson, MD – Internal Medicine -Specialist Medical Reviewer Stanford M. Shoor, MD – Rheumatology
Last Updated April 20, 2007

To view the slideshow on Knee Replacement to see what happens during this surgery log on to http://arthritis.webmd.com/knee-replacement-surgery.

©2005-2009 WebMD, LLC. All rights reserved. © 1995-2008 Healthwise, Incorporated

Six Surprising Stress Fixes

From the FMS Global and UK News Desk of Jeanne Hambleton

Courtesy of WebMD – Feature from “Good Housekeeping” Magazine USA

By Catherine Guthrie

Simple, field-tested strategies you can use right now

You know what stress looks like: The sun rises; so do you. Your child suddenly remembers that he needs cupcakes for the school party. The dog has gotten sick in the living room. Your spouse leaves for work in a huff after a pre-breakfast tiff over finances. You leave for work without a report that’s due today. You double back, grab it from the kitchen counter, trip over an Everest of laundry — must we go on?

You know what stress feels like: Your pulse quickens, your lungs squeeze shut, your ears ring, and you wonder if this is the time your head actually explodes. Sensing anxiety overload, your brain orders up a chemical surge that makes your blood vessels narrow, heart race, blood pressure rise, and muscles tighten. Your body is mobilizing to deal with threat.

Good plan, nature! But you were not meant to stay on red alert forever. Prolonged stress leads to health problems. High levels of the stress hormone cortisol are associated with heart disease and cancer; stress has also been linked to gastrointestinal problems, eczema, asthma, and depression.

And you probably already know what is involved in long-term, big-commitment stress reduction: physical changes (exercising, eating right, getting plenty of sleep); organizational changes (planning ahead, divvying up chores equitably); attitude changes (letting go of what you cannot control, for starters); and relationship changes (finding ways to talk through, directly and respectfully, the problems that are the sources of anxiety). All of these transformations are definitely worth the effort.

But here is what you may not know: Recent studies have suggested six new stress reducers — research-tested, rather surprising, and relatively simple. You can ease these strategies into your life right now.

Strategy 1: Smooch spontaneously

“When I come home from a hard day at work and kiss my husband, the bad stuff does not seem to matter anymore,” says Cheryl Kennedy Henderson, 47, an accountant in Knoxville, TN.

Science says she is on to something. A recent study of 2,000 couples showed that those who kiss only during lovemaking are eight times more likely to report suffering from stress and depression than those who frequently kiss on the spur of the moment. Study leader Laura Berman, Ph.D., an assistant clinical professor of psychiatry and ob-gyn at Northwestern University’s Feinberg School of Medicine, explains why: “Kissing relieves stress by creating a sense of connectedness, which releases endorphins, the chemicals that counteract stress and depression.”

Strategy 2: Take the cuddle cure

More good news from the annals of affection: Researchers at the University of North Carolina at Chapel Hill recently found that holding hands and hugging can measurably reduce stress. Fifty couples were asked to hold hands for 10 minutes, then hug for 20 seconds. A second group of 85 people rested quietly, not touching their significant others. Researchers then asked people in both groups to talk about a past event that left them angry or anxious. Those who had not cuddled before revisiting the past exhibited signs of elevated heart rate and blood pressure. But couples who had hugged and held hands were not nearly as ruffled.

“The gentle pressure of a hug can stimulate nerve endings under the skin that send calming messages to the brain and slow the release of cortisol,” explains Tiffany Field, Ph.D., director of the University of Miami Medical School’s Touch Research Institute. And if your honey is not on hand? Field says other studies have found that a hug from a friend or a professional massage can also help banish tension.

Strategy 3: Lash out less

You may have already concluded what a series of studies has confirmed: When married couples argue, men are more likely than women to withdraw — and this frustrates their wives. The studies also revealed something not as obvious. The way a woman deals with frustration during hostile arguments can measurably affect her stress load, and thus her physical health.

Women who responded to their husbands with verbal hostility showed elevated stress-hormone levels during arguments and for hours afterward. Their mates did not show these physical signs of stress, says Janice Kiecolt-Glaser, Ph.D., professor of psychiatry at Ohio State University College of Medicine and a member of the research team. Prolonged surges of stress hormones can damage the immune system, she notes.

One serious physical consequence of a hostile fighting style was discovered last year by researchers at the University of Utah, who found that wives who lashed out at their husbands during disagreements had twice as much coronary artery calcification, a sign of heart disease, as wives who stayed calm. Hostile husbands were not affected.

“Conflict is not necessarily bad,” says Kiecolt-Glaser. “It is the way couples disagree that affects health.” Her advice: Concentrate on the issue at hand and forget about getting even; drop the sarcasm and name-calling. “Generally it is best to try to keep the emotional temperature as low as possible,” she says. “The more heated the words or tone of voice, the harder it is for husbands and wives to hear each other. If necessary, take a deep breath and respectfully end the conversation, promising to talk about the situation later, when you are calmer.”

Strategy 4: Put the kettle on

Tea is the most popular beverage in the world (after water); even coffee-worshipping Americans guzzle more than 2 billion gallons of tea a year. Part of the appeal may be its tension-taming powers. In a recent study, scientists at University College London noted that people who drank black tea four times a day for six weeks had lower levels of cortisol after a stressful task than those who drank a caffeinated fruit beverage.

Research also shows that a substance in green tea leaves, L-Theanine, may shift brain wave activity from the beta waves that accompany anxiety to the alpha waves associated with relaxation. Maxine Friedman, 43, of New York City, the mother of 7-year-old twin girls, builds tea breaks into her busiest days. She finds the ritual as calming as the beverage. “I start relaxing even before I start to drink — at the sound of the kettle, the feel of the cup in my hand,” she says.

Strategy 5: Loosen your electronic leash

Thanks to high-tech gadgets, your kids can reach you 24/7. Knowing where they are and what they are up to? Priceless. But there is a hidden cost. A two-year study of 1,367 working men and women in New York State, two-thirds of them parents, found that all were overburdened by a blurring of the divide between the workplace and home. But while both men and women reported bringing job-related worries home with them, only women felt stress because of home worries spilling over into the workplace.

Researchers speculate that cell phones and pagers are responsible for this blurring of boundaries. “When your kids have a crisis or a relative gets sick, it is usually the women, not the men, who get the call at work,” says Noelle Chesley, a professor of sociology at the University of Wisconsin-Milwaukee and the study’s author. She suggests you take turns with your spouse being “on call” for minor emergencies, and make sure the sitter and the school have his number as well as yours. You may have to retrain the kids, too.

Strategy 6: Reflect on what you value

When your frazzle level is so high you feel yourself spiraling out of control, a quick way to re-center is to remind yourself of what is most important in your life. Researchers at the University of California, Los Angeles, asked 85 people to complete a questionnaire ranking their values from what matters most to what matters least. Then the group was divided. Half the people were asked to talk about their top-ranked values; the other half discussed what mattered least to them.

Afterward, everyone took part in a stress-inducing task (giving a five-minute speech in front of a heckling audience, then counting backward from 2,083 by 13s). People who had reflected on their most cherished values had a lower stress response than those who had discussed matters that did not mean much.

“Affirming your values changes the way you appraise a situation,” says David Creswell, Ph.D., the study’s lead author and a research scientist at UCLA. “In this case, the stressful event became less of a threat and more of a challenge.” He suggests one way to put the research findings to work: In a stressful situation, think about people important to you, and how you have been a good mate, mother, daughter, sister, or friend.

“Affirmations of close relationships are powerful sources to draw on,” Creswell says.
 
Stress Management

People who do not manage stress well can have headaches, stomach pain, sleeping problems, illness, and depression. You can manage stress by journaling, meditating, exercising, talking to others, or engaging in a hobby.

Stress Management Diet

Stress management can be a powerful tool for wellness. There is evidence that too much pressure is not just a mood killer. People who are under constant stress are more vulnerable to everything from colds to high blood pressure and heart disease. Although there are many ways to cope, one strategy is to eat stress-fighting foods. Read on to learn how a stress management diet can help.

Stress-Busting Foods: How They Work

Foods can fight stress in several ways. Comfort foods, like a bowl of warm oatmeal, actually boost levels of serotonin, a calming brain chemical. Other foods can reduce levels of cortisol and adrenaline, stress hormones that take a toll on the body over time. Finally, a nutritious diet can counteract the impact of stress, by shoring up the immune system and lowering blood pressure. Do you know which foods are stress busters?

Complex Carbs

All carbs prompt the brain to make more serotonin. For a steady supply of this feel-good chemical, it is best to eat complex carbs, which are digested more slowly. Good choices include whole-grain breakfast cereals, breads, and pastas, as well as old-fashioned oatmeal. Complex carbs can also help you feel balanced by stabilizing blood sugar levels.

Simple Carbs

Dieticians usually recommend steering clear of simple carbs, which include sweets and soda. But these foods can provide short-term relief of stress-induced irritability. Simple sugars are digested quickly, leading to a spike in serotonin.

Oranges

Oranges make the list for their wealth of vitamin C. Studies suggest this vitamin can reduce levels of stress hormones while strengthening the immune system. If you have a particularly stressful event coming up, you may want to consider supplements. In one study, blood pressure and cortisol levels returned to normal more quickly when people took 3,000 milligrams of vitamin C before a stressful task.

Spinach

Popeye never lets stress get the best of him – maybe it is all the magnesium in his spinach. Magnesium helps regulate cortisol levels and tends to get depleted when we are under pressure. Too little magnesium may trigger headaches and fatigue, compounding the effects of stress. One cup of spinach goes a long way toward replenishing magnesium stores. Not a spinach eater? Try some cooked soybeans, or a filet of salmon, also high in magnesium.

Fatty Fish

To keep cortisol and adrenaline in check, make friends with fatty fish. Omega-3 fatty acids, found in fish like salmon and tuna, can prevent surges in stress hormones and protect against heart disease. For a steady supply, aim to eat three ounces of fatty fish at least twice a week. 

Black Tea

Research suggests black tea can help you recover from stressful events more quickly. One study compared people who drank four cups of tea daily for 6 weeks with people who drank a tea-like placebo. The real tea drinkers reported feeling calmer and had lower levels of cortisol after stressful situations. Coffee, on the other hand, can boost levels of cortisol.

Pistachios

Pistachios can soften the impact stress hormones have on the body. Adrenaline raises blood pressure and gets your heart racing when you are under stress. Eating a handful of pistachios every day can lower blood pressure, so it will not spike as high when that adrenaline rush comes.

Avocados

One of the best ways to reduce high blood pressure is to get enough potassium — and half an avocado has more potassium than a medium-sized banana. In addition, guacamole offers a nutritious alternative when stress has you craving a high-fat treat.

Almonds

Almonds are chock full of helpful vitamins. There is vitamin E to bolster the immune system, plus a range of B vitamins, which may make the body more resilient during bouts of stress. To get the benefits, snack on a quarter of a cup every day.

Raw Veggies

Crunchy raw vegetables can fight the effects of stress in a purely mechanical way. Munching celery or carrot sticks helps release a clenched jaw, and that can ward off tension headaches.

Bedtime Snack

Carbs at bedtime can speed the release of serotonin and help you sleep better. Heavy meals before bed can trigger heartburn, so stick to something light like toast and jam.

Milk

Another bedtime stress buster is the time-honored glass of warm milk. Researchers have found calcium can reduce muscle spasms and soothe tension, as well as easing anxiety and mood swings linked to PMS. Dieticians typically recommend skim or low-fat milk.

Herbal Supplements

There are many herbal supplements that claim to fight stress. One of the best studied is St. John’s wort, which has shown benefits for people with mild-to-moderate depression. Although more research is needed, the herb also appears to reduce symptoms of anxiety and PMS. There is less data on valerian root, another herb said to have a calming effect.

(Ed’s note:You should perhaps seek medical advice before taking St. John’s Wort with other medication)

De-Stress with Exercise

Besides tweaking your diet, one of the best stress-busting strategies is to start exercising. Aerobic exercise is the most effective, because it increases oxygen circulation and produces endorphins — chemicals that make you feel happy. To get the maximum benefit, aim for 30 minutes of aerobic exercise three to four times a week.

(Ed’s note: Undertaking a new exercise regime should be subject to medical advice.)

Disclaimer: The views of the author of this article are not necessarily the views of the Editor. It in interest of self preservation, readers should seek medical advice before making any additions or changes to their prescriptions or undertaking any strenuous exercise. Without prejudice.

©2005-2009 WebMD, LLC. All rights reserved.
(http://www.webmd.com/balance/stress-management/features/6-surprising-stress-fixes)

Fear Keeps Many From Fighting RA Pain

From the FMS Global and UK News Desk of Jeanne Hambleton

Courtesy of WebMD.com
By Bill Hendrick – WebMD Health News- Reviewed by Louise Chang, MD

March 25, 2009 — Many people with rheumatoid arthritis may have barriers that hinder optimal management of their pain, a study suggests.

Barriers to pain reduction, Canadian researchers say, include fear of medication side effects, fear of drug interactions, worry about drug addiction, concerns that the effects of medication might mask the disease, and aversion to taking too many pills.

McGill University scientists studied 60 patients with rheumatoid arthritis, all of whom were being treated by specialists. Of the rheumatoid arthritis sufferers, 53% described their pain as moderate to severe.

Forty-seven percent reported that pain was mild or absent. And 65% of all patients, including about half of those with moderate to severe pain, were satisfied with current methods to control suffering, the researchers report in the March issue of The Journal of Pain.

Although 87% of the patients reported that they expected to have “some” pain to “much” pain from their rheumatoid arthritis, only 13% didn’t expect any pain or only slight pain.

The researchers, led by Mary-Ann Fitzcharles, MD, of Montreal General Hospital at McGill University, were interested in the potential barriers to reducing pain that kept some people hurting.

The top barriers to optimal pain management found in the study participants included:

Worry of medication side effects (80%)

Not wanting to take “too many pills” (63%)

Worry about medication interactions (57%)

Worry of addiction (35%)

The researchers found that more than half of the patients had at least three barriers.

The researchers conclude that people with rheumatoid arthritis should be questioned vigorously about their pain, and that clinicians should explore potential barriers to effective pain control.

News release, McGill University.
Fitzcharles, M. The Journal of Pain, March 2009; vol 10: pp 300-305.
© 2009 WebMD, LLC. All rights reserved.
(http://www.webmd.com/rheumatoid-arthritis/news/20090325/is-fear-keeping-you-from-fighting-ra-pain?ecd=wnl_cbp_040209)

Hand Exercises Aid Rheumatoid Arthritis

Muscle-strengthening exercises may ease pain and help individuals with RA improve their quality of life

By Gina Shaw -WebMD the Magazine – Feature Reviewed by Michael W. Smith, MD

For 25 years, New Yorker Carol Solomon, 69, ran a knitting store. In 2006, a few years into retirement, she was diagnosed with rheumatoid arthritis (RA) in both hands.

“I have movement in my thumb and in my pointer finger, but my other three fingers are pretty stiff,” she says. Solomon did not want to give up the knitting and sewing she loves, so she sought help from her doctor and physical therapists at New York’s Hospital for Special Surgery.

There is a saying about exercise and RA: Use it, but do not abuse it.

“Studies have shown that strengthening the muscles around the joints leads to overall improved function and better quality of life,” says Heather Williams, DPT, a physical therapist in the Hospital for Special Surgery’s Joint Mobility Center.

“Patients can be afraid to exercise those joints because of pain, but they really benefit from strengthening exercises.”

RA is an autoimmune disease in which the body attacks its own tissues. It is a chronic disease, but when diagnosed and treated early with a combination of medication and physical therapy, joint damage can be limited.

When it affects the hands or wrists, like Solomon’s, some helpful exercises include squeezing small exercise balls or putting the hand out flat, palm up, and bending each finger one by one into the palm. Take it slowly, advises the physical therapist. She says Solomon should try three sets of five repetitions of each exercise instead of 10 or 12 reps — and then work up to more as she builds her strength.

People with RA go through phases called “flare-ups,” with extremely swollen and painful joints, and then “subacute” phases when the disease is less active. Modifying activity depending on what phase you are in is important, says Theodore Fields, MD, clinical director of the Gosden-Robinson Early Arthritis Center at New York’s Hospital for Special Surgery.

“When you have a significant flare-up, the joints need more rest.”

Whatever kind of exercise you do, be sure to discuss your exercise plan with a physical therapist who understands RA.

“Have your physical therapist work out a home-exercise program that fits your needs and respects the joints you have trouble with,” says Fields.

Solomon knows her knitting needles will never fly like they used to, but she has started to work with yarn again and can even sew with a needle and thread, an impossible feat when she first was diagnosed.

“I am just seeing what I can do every day, and trying to adjust the way I do things to give myself as much function as possible,” she says.

Hand Exercise for Rheumatoid Arthritis

The Exercise:
Fill an empty box with small items such as nuts, screws, and bolts. Reach in and, handful by handful, pick the screws and bolts out of one box, place them in your other hand, and place in a second box.

The Benefit:
This exercise helps strengthen muscles around joints for improved finger mobility and helps prevent future joint damage.

Originally published in the September/October 2007 issue of WebMD the Magazine. © 2007 WebMD, Inc. All rights reserved.
(http://www.webmd.com/rheumatoid-arthritis/features/hand-exercises-aid-rheumatoid-arthritis?ecd=wnl_cbp_040209)

Nuclear Medicine: New World of Diagnosing and Treating Illness

From the FMS Global News Desk of Jeanne Hambleton

Courtesy of the Society of Nuclear Medicine – Advancing Molecular Imaging and Therapy
(https://interactive.snm.org/)

IMAGES THE BODY’S BIOLOGICAL PROCESSES

Nuclear medicine is a medical specialty that uses very small amounts of radioactive materials (radiopharmaceuticals) to diagnose, guide management and treat disease. Most nuclear medicine procedures are molecular imaging procedures that use radioactive substances. Molecular imaging procedures are highly effective, safe and painless diagnostic imaging and treatment tools that present physicians with a detailed view of what is going on inside an individual’s body at the cellular level.

Molecular imaging/nuclear medicine specialists can safely, effectively and painlessly determine if certain organs, such as the heart, brain, kidneys, liver, thyroid and lungs, are working properly. A molecular imaging/nuclear medicine procedure commonly used in diagnosing and guiding treatment of cancer patients is PET/CT scanning (see also “PET/CT Scanning: Get the Facts” – see below).

When very small amounts of radioactive materials are introduced into the body by injection, swallowing or inhalation, specific body organs can be targeted. These trace radiopharmaceuticals are detected by special cameras that work with computers to provide pictures of an area of the body, offering information about an organ’s physiology or function. The presence of disease is determined based on biological or molecular changes, rather than changes in anatomy. Radiopharmaceuticals go directly to the organ being targeted and are also used as treatment for hyperthyroidism, certain types of cancer such as thyroid and lymphoma, blood imbalances and pain relief for certain types of bone cancer.

Improves Patient Care

Today, molecular imaging and nuclear medicine offer procedures that are essential in many medical specialties, from pediatrics to cardiology to neurology to oncology. Molecular imaging and nuclear medicine procedures are an invaluable way to gather medical information that would otherwise be unavailable, require surgery or necessitate more expensive diagnostic tests.

These commonly performed biological imaging procedures are an integral part of patient care, identifying abnormalities very early in the progression of a disease-often before medical problems are apparent with other diagnostic tests. Early detection allows a disease to be treated when there may be a more successful prognosis.

Helps in Diagnosis and Treatment

In 2007, an estimated 16 million patients received nuclear medicine procedures in over 7,300 hospital and non-hospital sites in the United States, or approximately 68,000 patients daily (http://www.imvinfo.com). Nearly all hospitals-in addition to many clinics and private doctors’ offices-perform nuclear medicine tests and scans. Safe, effective, painless and commonly performed procedures include positron emission tomography (PET) scans to diagnose and monitor treatment in cancer, cardiac stress tests to analyze heart function, bone scans for orthopedic injuries and lung scans for blood clots.

More than 100 different nuclear medicine imaging procedures are available, and every major organ system can be imaged. Nuclear medicine procedures are used in the diagnosis and evaluation of treatment of:

Neurological diseases
Alzheimer’s disease and dementias
Seizure disorders
Coronary artery disease
Many types of cancer
Endocrine diseases
Thyroid
Parathyroid
Adrenal
Gastrointestinal diseases
Stomach
Liver and gallbladder
Genitourinary diseases
Kidneys
Bladder
Testicles
Pulmonary diseases
Bone diseases
Trauma
Infections

SNM and Nuclear Medicine

SNM is an international scientific and medical organization dedicated to raising public awareness about what molecular imaging is and how it can help provide patients with the best health care possible. SNM members specialize in molecular imaging, a vital element of today’s medical practice that adds an additional dimension to diagnosis, changing the way common and devastating diseases are understood and treated.

SNM’s more than 17,000 members set the standard for molecular imaging and nuclear medicine practice by creating guidelines, sharing information through journals and meetings and leading advocacy on key issues that affect molecular imaging and therapy research and practice. For more information, visit http://www.snm.org.

WHAT IS NUCLEAR MEDICINE?

Nuclear medicine specialists use safe, painless, and cost-effective techniques to image the body and treat disease. Nuclear medicine imaging is unique, because it provides doctors with information about both structure and function. It is a way to gather medical information that would otherwise be unavailable, require surgery, or necessitate more expensive diagnostic tests. Nuclear medicine imaging procedures often identify abnormalities very early in the progress of a disease – long before many medical problems are apparent with other diagnostic tests.

Nuclear medicine uses very small amounts of radioactive materials (radiopharmaceuticals) to diagnose and treat disease. In imaging, the radiopharmaceuticals are detected by special types of cameras that work with computers to provide very precise pictures about the area of the body being imaged. In treatment, the radiopharmaceuticals go directly to the organ being treated. The amount of radiation in a typical nuclear imaging procedure is comparable with that received during a diagnostic x-ray, and the amount received in a typical treatment procedure is kept within safe limits.

Today, nuclear medicine offers procedures that are essential in many medical specialties, from pediatrics to cardiology to psychiatry. New and innovative nuclear medicine treatments that target and pinpoint molecular levels within the body are revolutionizing our understanding of and approach to a range of diseases and conditions.

Would you like to know more about Nuclear Medicine? The SNM has two versions of our What Is Nuclear Medicine brochure available for download and bulk purchase. One is for General Educational Purposes and the second brochure is geared for Patients.

To download the Patients Brochure log on to
http://interactive.snm.org/docs/whatisnucmed2.pdf

© 2009 SNM. All rights reserved
(http://interactive.snm.org/index.cfm?PageID=3106&RPID=#URL.PageID%23)

WHAT IS PET?

Positron Emission Tomography (PET) is a major diagnostic imaging modality used predominantly in determining the presence and severity of cancers, neurological conditions, and cardiovascular disease. It is currently the most effective way to check for cancer recurrences, and it offers significant advantages over other forms of imaging such as CT or MRI scans in detecting disease in many patients. In 2005, an estimated 1,129,900 clinical PET patient studies were performed at 1,725 sites around the country. If you’re interested in learning how a PET scan can benefit you and need additional information, talk with your local health care provider or referring physician. At the end of this page are links to other sites with PET information too.

PET images demonstrate the chemistry of organs and other tissues such as tumors. A radiopharmaceutical, such as FDG (fluorodeoxyglucose), which includes both sugar (glucose) and a radionuclide (a radioactive element) that gives off signals, is injected into the patient, and its emissions are measured by a PET scanner.

A PET scanner consists of an array of detectors that surround the patient. Using the gamma ray signals given off by the injected radionuclide, PET measures the amount of metabolic activity at a site in the body and a computer reassembles the signals into images. Cancer cells have higher metabolic rates than normal cells, so they show up as denser areas on a PET scan. PET is useful in diagnosing certain cardiovascular and neurological diseases because it highlights areas with increased, diminished or no metabolic activity, thereby pinpointing problems.

Cancer and PET

PET is considered particularly effective in identifying whether cancer is present or not, if it has spread, if it is responding to treatment, and if a person is cancer free after treatment. Cancers for which PET is considered particularly effective include lung, head and neck, colorectal, esophageal, lymphoma, melanoma, breast, thyroid, cervical, pancreatic, and brain as well as other less-frequently occurring cancers.

Early Detection:

Because PET images biochemical activity, it can accurately characterize a tumor as benign or malignant, thereby avoiding surgical biopsy when the PET scan is negative. Conversely, because a PET scan images the entire body, confirmation of distant metastasis can alter treatment plans in certain cases from surgical intervention to chemotherapy.

Staging of Cancer: PET is extremely sensitive in determining the full extent of disease, especially in lymphoma, malignant melanoma, breast, lung, colon and cervical cancers. Confirmation of metastatic disease allows the physician and patient to more accurately decide how to proceed with the patient’s management.

Checking for recurrences:

PET is currently considered to be the most accurate diagnostic procedure to differentiate tumor recurrences from radiation necrosis or post-surgical changes. Such an approach allows for the development of a more rational treatment plan for the patient.

Assessing the Effectiveness of Chemotherapy:

The level of tumor metabolism is compared on PET scans taken before and after a chemotherapy cycle. A successful response seen on a PET scan frequently precedes alterations in anatomy and would therefore be an earlier indicator of tumor response than that seen with other diagnostic modalities.

PET and CT or MRI

Because PET measures metabolism, as opposed to MRI or CT, which “see” structure, it can be superior to these modalities, particularly in separating tumor from benign lesions, and in differentiating malignant from non-malignant masses such as scar tissue formed from treatments like radiation therapy. PET is often used in conjunction with an MRI or CT scan through “fusion” to give a full three-dimensional view of an organ and the location of cancer within that organ. The newest PET scanners are a combination of PET and CT devices that provide the important metabolic information from PET superimposed on the high-quality anatomic information from CT.

Neurological Disease

PET’s ability to measure metabolism also has significant implications in diagnosing Alzheimer’s disease, Parkinson’s disease, epilepsy and other neurological conditions, because it can vividly illustrate areas where brain activity differs from the norm.

Alzheimer’s Diagnosis: Until recently, autopsy has been considered the only definitive test for Alzheimer’s disease (AD). Recent studies indicate that PET can supply important diagnostic information and confirm an Alzheimer’s diagnosis. When comparing a normal brain versus an AD-affected brain on a PET scan, a distinctive image appears in the area of the AD-affected brain. This pattern is seen very early in the AD course. Conventionally, the confirmation of AD is a long process of elimination that averages between two and three years of diagnostic and cognitive testing. Early diagnosis can provide the patient access to therapies, which are more effective earlier in the disease.

PET also is useful in differentiating Alzheimer’s disease from other forms of dementia disorders, such as vascular dementia, Parkinson’s disease, Huntington’s disease, etc.

Epilepsy:

PET is one of the most accurate methods available to localize areas of the brain causing epileptic seizures and to determine if surgery is a treatment option.

Cardiovascular Disease

By measuring both blood flow (perfusion) and metabolic rate within the heart, physicians using PET scans can pinpoint areas of decreased blood flow, such as those with blockages, and differentiate living muscle from damaged muscle, which has inadequate blood flow (myocardial viability). This information is particularly important in patients who have had previous myocardial infarction (heart attack) and who are being considered for a procedure such as angioplasty or coronary artery bypass surgery.

Cost & Reimbursement:

PET scan charges range from $850–$4,000, depending on the type of scan. American Insurance companies will cover the cost of many PET scans. Medicare reimburses for almost all cancers. Some indications have already been determined to be reimbursable, others are reimbursed as long as they are part of a qualified clinical trial or a clinical study to determine the effectiveness of PET in imaging specific cancers. Medicare is constantly updating reimbursements, so visit the SNM Web site to find the latest information.

History of PET

In the 1970s PET scanning was formally introduced to the medical community. At that time it was seen as an exciting new research modality that opened doors through which medical researchers could watch, study, and understand the biology of human disease.

In 1976, the radiopharmaceutical fluorine-18-2-fluoro-2-deoxyglucose (FDG), a marker of sugar metabolism with a half-life of 110 minutes, enabled tracer doses to be administered safely to the patient with low radiation exposure. The development of radiopharmaceuticals like FDG made it easier to study living beings, and set the groundwork for more in-depth research into using PET to diagnose and evaluate the effect of treatment on human disease.

To perform PET studies in the late 1970s, a large staff was needed: physicists to run the cyclotron that produces the fluorine-18 and to oversee the scanner, chemists to make the tracers such as FDG, and dedicated, specialist physicians.

During the 1980s the technology that underlies PET advanced greatly. Commercial PET scanners were developed with more precise resolution and images. As a result, many of the steps required for producing a PET scan became automated and could be performed by a trained technician and experienced physician, thereby reducing the cost and complexity of the procedure. Smaller, self-shielded cyclotrons were developed, making it possible to install cyclotrons at more locations.

Over the last several years, the major advance in this technology has been the combining of a CT scanner and a PET scanner in one device. The modern PET/CT scanner allows a study to be done in a shorter amount of time but still provides more diagnostic information.

PET Today

PET and PET/CT are widely available today. The technology is robust and provides high-quality images. Some of the earlier roadblocks to having or using a PET or PET/CT device—such as availability of particular radiopharmaceuticals—are no longer present.

Reviewed by R. Edward Coleman, MD

© 2009 SNM. All rights reserved.