Category Archives: Pain-Relief

Physical Therapy After Knee Replacement Linked to Less Long Term Opioids for Pain Relief

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PainRelief.com Interview with:
Deepak Kumar, PT, PhD
Assistant Professor, Physical Therapy
Assistant Professor, BU School of Medicine
Director, Movement & Applied Imaging Lab

Dr. Kumar

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: We investigated the association of physical therapy interventions with long-term opioid use in people who undergo total knee replacement surgery.   For people with advanced osteoarthritis, total knee replacement is the only option. The number of total knee replacement surgeries has been increasing and is expected to rise exponentially over the next few years with an aging population and rising rates of obesity. However, up to a third of patients continue to experience knee pain after this surgery. Also, a significant proportion of people become long-term opioid users after total knee replacement. Reliance on opioids may reflect a failure of pain management in these patients. Given that physical therapy interventions are known to be effective at managing pain due to knee osteoarthritis, we wanted to study whether physical therapy before or after surgery may reduce the likelihood of long-term opioid use.

We used real-world data from insurance claims for this study. In our cohort of about 67,000 patients who underwent knee replacement between 2001-2016, we observed that, receiving physical therapy within 90 days before surgery or outpatient physical therapy within 90 days after surgery were both related to lower likelihood of long-term opioid use later. We also observed that initiating outpatient physical therapy within 30 days and 6 or more sessions of physical therapy were associated with reduced likelihood of long-term opioid use compared to later initiation or fewer PT sessions, respectively. However, we did not see an association between type of physical therapy. i.e., active (e.g., exercsise) vs. passive (e.g., TENS) and long-term opioid use.

Importantly, most of our findings were consistent for people who had or had not used opioids previously. We also were able to account of a larger number of potential factors that could confound these associations because of the large sample size. However, there are limitations to our work. Since we only had access to insurance claims data but not to health records, we are unable to make any inferences about association of physical therapy with pain or quality of life, etc.

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UCI Scientists Discover Pathway Blocking Transition from Acute to Chronic Pain

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PainRelief.com Interview with:

Daniele Piomelli PhD Distinguished Professor, Anatomy & Neurobiology Louise Turner Arnold Chair in Neurosciences Joint Appointment, Biological Chemistry and Pharmacology School of Medicine Director, Center for the Study of Cannabis University of California, Irvine
Dr. Piomelli

Daniele Piomelli PhD
Distinguished Professor, Anatomy & Neurobiology
Louise Turner Arnold Chair in Neurosciences
Joint Appointment, Biological Chemistry and Pharmacology
School of Medicine
Director, Center for the Study of Cannabis
University of California, Irvine

PainRelief.com: What is the background for this study?

Response: The pain caused by physical trauma or by surgery can disappear in a relatively short time — or linger for months or even years. In some cases, for example after open heart surgery, the percent of people who develop persistent pain can be as high as 40%. Breast and knee surgery, among others, have similar outcomes. We still don’t understand how acute pain after an injury becomes chronic.  

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Brainstem’s Role in Placebo and Pain Perception Highlighted

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PainRelief.com Interview with:
Lewis Crawford, B.Sci (Hons), PhD Candidate 
Neural Imaging Laboratory | Faculty of Medicine and Health
University of Sydney 

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: This study was performed as a means to accurately and robustly define the areas of the brainstem responsible for alleviating and enhancing pain via conditioning and expectation alone, that is, the phenomena of placebo analgesia and nocebo hyperalgesia. The reason we were able to do this was by being able to access a 7-tesla ultra-high field MRI, one of only two in Australia, that allowed us to resolve the small nuclei in the brainstem which make up descending analgesic circuitry (they carry signals from your brain to your spinal cord).

We found that a central pathway, comprised of the midbrain Periaqueductal Gray (PAG) and Rostral Ventromedial Medulla (RVM), acted during both phenomena, however in opposite ways. We also identified several other nuclei as playing a role in the modulation of pain which, prior to this study, had not been explored or suggested to play a role in this context. We believe that the brainstem circuitry we defined here enables further research into mechanisms responsible for analgesia and hyperalgesia and will promote further investigation into brainstem function in humans. 

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Tramadol Prescriptions for Pain Relief Linked to More Complications than Codeine

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PainRelief.com Interview with:
Carlen Reyes PhD
Médico de familia
Gestora de proyectos de investigación IDIAP Jordi Gol

PainRelief.com: What is the background for this study? What are the main findings?

Response: Tramadol and codeine are two “weak” opioids frequently prescribed for different non-cancer pain indications, however, few are the studies that compare the adverse outcomes between them using large routinely collected primary care data. We aimed to fulfil this gap by analysing the risk of adverse events with the tramadol and codeine dispensations in a large primary care health care data (SIDIAP database) from Spain. 

We found that the dispensations of tramadol were associated with a greater risk of cardiovascular events, mortality and fractures compared to the dispensations of codeine. 

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Survey of Medical Cannabis Effects on Anxiety and Depression

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PainRelief.com Interview with:
Erin Martin Ph.D. Candidate
Department of Neuroscience
Medical University of South Carolina
Charleston, SC 29425

Erin Martin

PainRelief.com:  What is the background for this study?
Response: Anxiety and depressive disorders are highly prevalent. People with these disorders are increasingly using cannabis products for symptom management, either as an alternative to or in conjunction with traditional antidepressants.

The goal of this study was to examine the effect of medicinal cannabis product use on symptoms of anxiety and depression in a clinical population, and to assess important correlates of anxiety and depression such as chronic pain and quality of life.  

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Study Addresses How Weather Affects Pain Tolerance

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PainRelief.com Interview with:
Erlend Hoftun Farbu, PhD student
Department of Community Medicine
The Arctic University of Norway
Tromsø, Norway

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Many report that weather affect their pain condition. Some studies confirm this, others do no. However, these studies have asked “How much pain do you have today?”

We used two tests to assess how much pain a person can tolerate. We then looked at how pain tolerance vary over time and if they are associated with weather.

The results show quite clearly that people can tolerate more pain caused by intense cold temperature in the colder months of the year. There was no such seasonal variation in pain caused by pressure to the leg. On the other hand, we found that both pressure pain tolerance and weather at one day was associated with the next days, but not the next month. When we further linked the weather and pain tolerance, we found that, for example, in some periods a rise in temperature happened at the same time as a rise in pain tolerance. While in other periods, there were no such association. We mean that this is because we adapt to the weather. For example, how we experience 5 °C (41°F) is different in autumn and spring..

Finally, temperature and barometric pressure could predict future values of pressure pain tolerance

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Acetaminophen (paracetamol) During Pregnancy May Alter Fetal Development

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PainRelief.com Interview with:
Ann Z. Bauer ScD
Department of Work Environment
University of Massachusetts Lowell | UML 

PainRelief.com:  What is the background for this study?  What are the main findings of the underlying studies?

Response: Acetaminophen (paracetamol, brand name Tylenol) is an over-the-counter medication used to relieve pain and reduce fever. It is an active ingredient in over 600 medications and used by more than 50% of pregnant women worldwide and up to 65% of pregnant women in the US.

Current guidance recommends acetaminophen as the pain reliever of choice during pregnancy, as other pain relievers such as ibuprofen and aspirin are contraindicated during pregnancy, particularly after 20 weeks.

In this consensus statement the authors reviewed the research on acetaminophen use during pregnancy from 1995 through 2020 and found a growing body of evidence that suggests prenatal acetaminophen exposure may alter fetal development increasing the risk of neurodevelopmental, reproductive and urogenital disorders. Importantly, this review identifies a convergence of evidence from the trifecta of research areas -human cohort studies, in vitro and animal models. This statement asking for precaution and more research was supported by a total of 91 clinicians and researchers (13 authors and 78 signatories) from around the world.

Research suggests acetaminophen is an endocrine disruptor meaning it interferes with the proper functioning of hormones, specifically it is an anti-androgen that can significantly reduce testosterone production.  Acetaminophen exposure during pregnancy has been suggested to increase the risk of male undescended testicles (cryptorchidism) and shorter anogenital distance (ADG) a marker of sub-fertility.  Additionally, research suggests increased risk of neurodevelopmental disorders primarily attention deficit hyperactivity disorder (ADHD) and related behavioral abnormalities, but also autism spectrum disorder (ASD), language delays, decreased IQ, and conduct disorders.

Many users do not consider acetaminophen to be a medication with potential side effects. There is high usage, in part, because of a perception  that use is of negligible risk.  However, because use is so common, if acetaminophen is responsible for even a small increase in individual risk it could contribute substantially to these disorders in the overall population.

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Pain Relief Study of Low Carb Ketogenic Diet

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PainRelief.com Interview with:
Rowena Field
B.App.Sc (phty) M.Physio. APAM
Physiotherapist/Director
PhD research candidate Sydney University
STEPP (solutions tools and education for persistent pain)

PainRelief.com:  What is the background for this study?

Response: Chronic pain is a difficult problem to treat because it is multifactorial, driven by the brain continuing to arrive at the conclusion that protection is required. Turning up the sensitivity in the nervous system results in ongoing pain as a protector even though there is no new tissue damage. Other protection mechanisms such as increased inflammation, and increased sympathetic ‘fight or flight’ also occur.

Chronic pain becomes part of a whole system protective response, so looking at other treatment options that alter the system (such as diet) are useful additions to pain management. A ketogenic diet restricts carbohydrate to below 50g/day producing ketones for energy from fat. It has been used to treat epilepsy over the last two centuries and successfully reduces nervous system excitability. Many of the drugs used for chronic pain (such as Lyrica) are also anti-epileptic medications, suggesting common pathways. As well as these impacts on the nervous system, pre-clinical research has also shown ketones to be signalling molecules that reduce inflammation.

Combined with the clinical reports that pain reduction occurred when people were on ketogenic diets, it seemed reasonable to test the diet specifically in a chronic pain population.

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Knee Arthritis: Racial Differences in Treatment Patterns and Health Care Expenditures

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PainRelief.com Interview with:
Stuart L. Silverman MD FACP FACR
Clinical Professor of Medicine, Cedars-Sinai Medical Center and UCLA School of Medicine
Medical Director, OMC Clinical Research Center
Beverly Hills, CA 90211

Dr. Silverman

PainRelief.com:  What is the background for this study?

Response: As a practicing rheumatologist, I am aware that prior studies have shown variation in medical care, pain management and treatment with opioids by race and social economic status.  Suboptimal treatment of pain in patients with osteoarthritis (OA) may also disproportionately burden racial minorities and Medicaid recipients. 

Studies have shown that African Americans are nearly 1.5 times as likely to have symptomatic knee OA than White patients even when adjusting for other factors.  Similarly, they also have a higher prevalence of symptomatic and radiographic hip OA.  Analyses of Medicare data has shown evidence of persistent racial disparities for joint arthroplasty usage and surgical outcomes.

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Physicians Differently Prescribe Pain Relief Medications to White and Minority Patients

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PainRelief.com Interview with:
Dan P. Ly M.D., M.P.P., Ph.D.
Division of General Internal Medicine and Health Services Research
David Geffen School of Medicine
University of California, Los Angeles

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: We know that minority patients were less likely to receive opioids than white patients, but this could have been due to minority patients seeing lower opioid-prescribing physicians. As far as I could tell, nobody had been able to examine whether the same physician prescribed opioids differently to their minority patients.

I find that this is the case: the same physician was less likely to prescribe opioids to their minority patients with new low back pain, and instead was more likely to prescribe NSAIDs to their minority patients. And unfortunately, this differential prescribing may have had the consequence of leading to more chronic opioid use in white patients.  

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