The Scan That Didn‘t Scan a Short Circuit of Pain The Short Circuit of Pain May Be Real, but the Scan Is Deceiving Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It‘s an issue particularly for the millions of people who go to doctors‘ offices in pain. The scans are expensive — Patient pay about Rs 4000 to 6000 for an M.R.I. scan of a knee or back, for example. This expense is not covered by medical insurance without hospitalization in India. And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain. But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal. ―A patient comes in because he‘s in pain,‖ said Dr. Vasant Panchal, a senior pain specialist at the Panchal Pain Clinic. ―We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.‖ Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery. ―Every time we get a new technology that provides insights into structures we didn‘t encounter before, we end up saying, ‗Oh, my God, look at all those abnormalities.‘ They might be dangerous,‖ said Dr. Vasant Panchal, a Interventional pain specialist. ―Some are, some aren‘t, but it ends up leading to a lot of care that‘s unnecessary.‖ ―I feel that I have come full circle,‖ she said. ―I will cope on my own with this knee.‖ It‘s two body parts — back and other is the knee — where there are good data on abnormalities that turn up in people who feel just fine, indicating that the abnormalities may not be so abnormal after all. But even the data on knees comes from just one study, and researchers say the problem is far from fixed. It is difficult to conduct scans on people who feel fine — most do not want to spend time in an M.R.I. and CT scans machine. But that leaves patients and doctors in an untenable situation. ―It‘s a concern, isn‘t it?‖ said Dr. Vasant Panchal, ―We are trying to fix things that shouldn‘t be fixed.‖ As a rheumatologist, Dr. Bankim Desai, saw patient after patient with knee pain, many of whom had already had scans. And he was becoming concerned about their findings. Often, a scan would show that a person with arthritis had a torn meniscus, cartilage that stabilizes the knee. But, Dr. Panchal wondered, was the torn cartilage an injury causing pain or was the arthritis causing pain and the tear a consequence of arthritis? ‖I wouldn‘t equate a negative scan as being an 100 percent indicator that nothing is wrong,‖ he added. So if you are told nothing is wrong because a scan was negative and you are having alarming symptoms, you may want to seek a second opinion. And don‘t forget, said Dr.Vasant Panchal, a pain specialist, the point of an M.R.I., or any imaging study, is to help make a diagnosis that will improve your health. Often imaging is unnecessary: a good exam will reveal what‘s wrong, and the treatment will be the same with or without the scan. Just as big a problem as the erratic quality of scans is the tendency of doctors and patients to rely on them too much. ―There‘s been a shift in medicine toward relying on imaging instead of a history and examination,‖ Dr. Panchal said Short circuit of faulty wiring mystifies mechanics and doctors alike A car's mysterious emission's problem shares similarities with the elusive neurological disorder, neuralgia. I was confident at the car emission inspection station before going on long drive. My car was driving fine. But I got a shock that day: a black rejection sticker for emissions. "Get a tune up," I was urged. When that didn't work, the repairs began. A new battery, a new alternator, a second battery - still I failed. I began to realize that my problem was not actually emissions, which were perfect, but electrical problems that prevented storage of my auto's emissions data. Somewhere during the garage visits and phone calls, it occurred to me that my car had the same problem as my patients with neuralgia, a type of chronic pain caused by nerve damage. They are laid low by pain in various locations, but medical exams and tests often show no cause. Their problem is not actually where their pain is felt, but in the nerves that carry pain messages to the brain. Normally, pain neurons only fire briefly during injury or illness to signal a problem, but short-circuits can make them fire continually, just like my engine warning light that stayed lit for months. Some neuralgia patients, whose symptoms are often triggered by common conditions such as shingles, diabetes, and osteoarthritis of the spine, are prescribed effective medications and may get pain relief. More often their "mystery pain" goes untreated as doctors fail to recognize and treat its neurological causes. And physicians, no matter how caring, must also weigh the chances of peer criticism when prescribing strong pain medicines for patients without sufficient explanation for their pain. Many neuralgia patients undergo unnecessary repairs just like my car. These include local-anesthetic injections that help only briefly while the area is numbed. I remember the woman whose dentist tried to treat her neurological jaw pain by doggedly extracting one innocent molar after another, leaving her toothless and impoverished, and no better. Most surgeries do not help neuralgia, and surgery causes or worsens many cases. In addition to living with chronic pain, my patients have to cope with an unforgiving medical and disability system with little tolerance for elusive problems. Medical tests aren't sensitive enough to detect subtle electrical problems, just as my mechanic's tests couldn't find the fault that was causing loss of my car's emission's data. Lack of evidence is interpreted as evidence of lack of a problem, and my patient's symptoms are attributed to psychological causes, character flaws, or to just plain lying to con a doctor into writing a narcotic prescription. With each new agency, each new doctor, my patients need to retell their complicated histories to convince yet another skeptical listener. Most feel vaguely guilty for having such a difficult problem, and many wonder at some point if i ndeed they might be crazy. Some cry with relief when I tell them that I have seen their kind of problem before and it is caused by neurological damage, not neurosis. Some eventually give up, traumatized twice - once by their illness and once by our system. I am haunted by the memory of a woman who killed herself last year, believing this the only way to end her suffering. But my lawfulness is temporary. My car's nerves are still fickle and my check engine light still goes on and off at will. I must expect rejection at my next emissions test. I've heard that Motor Vehicles is ending tailpipe-emissions testing altogether, which will leave no option for cars like mine to pass. Will we have to junk otherwise well -running cars that can't meet the new rules? Given the complexity of our own neurological wiring, perhaps physicians, medical insurers, and disability boards should also make provisions, so that patients with chronic pain from wiring problems can still get the care and compassion they need. TOP 10 TIPS TO HELP RESTORE INTIMACY If you find it difficult to maintain intimacy with your partner, you’re not alone. Surveys of couples living with chronic pain find as many as three out of four have little or no sexual contact. So take steps to help restore intimacy between you and your partner. 1. Learn to talk about it. The most important step is to start (and maintain) a dialogue with your partner—one that is free of blame and focuses on ways to be more intimate. Be open about sharing your fears and concerns, and set manageable goals together. 2. Spend quality time together without distraction. Carve out time go for a long walk, meet for coffee or plan a weekend getaway. 3. Think about sex in a different way. Even if you are unable to engage in sexual intercourse as frequently as you used to, it doesn’t mean that your sexual relationship has to end. Broaden your idea of “sex.” Learn what feels good to you and your partner. 4. Experiment, experiment, experiment. Think of creative ways to show your affection—try different positions, other types of stimulation, cuddling, caressing and massage. 5. Agree on a non-verbal sign. Think of a visual way to let your partner know you’re available and willing to try. For example, you might light a candle, draw a bath or use a specific pillowcase. 6. Monitor your pain and make a date. Track your pain using a pain notebook, available at www.painfoundation.org. Schedule time to be physically intimate with your partner. Pick a time of day when you have the most energy and are least likely to have a pain flare. 7. Take care of yourself and listen to your body. Be persistent about getting your pain to a tolerable level. If you don’t f eel well enough to engage in sexual activity, don’t force it. If you do, you risk associating pain with sex, which often leads to a vicious cycle of avoidance. Take small steps. It may be easier for the person with pain to initiate sexual activity so he or she has more control. 8. Relax. It may be easier said than done, but it’s important to relax and feel vulnerable with your partner. Begin by using simple breathing and relaxation exercises: And sex can help too. Not only is it a natural and healthy part of life, sex can naturally reduce pain sensations by releasing endorphins and lowering stress. 9. Practice positive self talk. You may feel unattractive or less than a whole person because your body feels broken, but you deserve to find a level of intimacy that works for you and plenty of people with pain do. Try not to dwell on things you can’t do. 10. Seek professional help. Find a Dr or qualified sex therapist willing to work with you and your partner. Many medications can reduce your interest in sex (libido) or ability to get or stay aroused. Talk with your healthcare provider about possible alternatives. Pain management clinics are necessary Dont allow pain to control your life. your goal is to manage your pain, not let it manage you. Most people in India unaware of their existence Advanced countries treat pain as a speciality, while India has only a few specialised clinics. Most people are unaware of their existence and continue to suffer in silence. Eighty-five per cent of people who walk into a doctor's clinic complain of pain. But not much importance is given to pain management & pain specialists. Pain should be considered a disease and treated to ensure quality life to people, they say. "For instance, someone may have a backache; MRI scans and X-rays may not show up anything. But the person will continue to suffer. Pain specialists will be able to diagnose it better. The standard procedure, according to him, should be to refer such a patient to pain management clinics. In the United States, this is a recognized specialty. CANCER PAIN Palliative Care and Pain Treatment as Human Rights Alarmed That of the more than 1 million people who die each week, only a minority of those in need receive palliative care resulting in widespread unnecessary suffering; That in spite of the great advances in the treatment of pain, developing countries, which represent about 80 percent of the world’s population, account for only about 6 percent of global consumption of morphine. Governments Should Improve Access to Pain Treatment Millions Worldwide Suffer Unnecessarily The Declaration on the Promotion of Patients’ Rights in Europe asserts: “Patients have the right to relief of their suffering according to the current state of knowledge” and “Patients have the right to humane terminal care and to die in dignity”8 ; Governments around the world, including thos e in low and middle inc ome countries, should take urgent action to stop the unnecessary suffering of millions of people from severe but treat able pain, Human Rights Watch said " Allowing millions of people to suffer unnecessarily when their pain can be effectively treated violates their right to the best possible health. " Lohman, senior researcher in the HIV/AIDS program of Human Rights Watch Tens of millions of people worldwide suffer from severe pain due to canc er, HIV and AIDS, and other health conditions. Although most pain can be treated effectively with inexpensive medications, government inaction or obstruction denies its victims access to pain treatment in many countries. ―Allowing millions of people to suffer unnecessarily when their pain can be effectively treated violat es their right to the best possible health,‖ said Diederik Lohman, senior researcher in the HIV/AIDS program of Human Rights Watch. ―Policy makers worldwide can and should address this.‖ Eighty percent of the world‘s people do not have adequate access to pain treatment, the World Health Organization (WHO) estimates. This is often due to overzealous drug control efforts and poor training for health care workers. Severe pain is a common symptom of cancer, HIV/AIDS, and other life-t hreatening conditions, especially in the late stages. An estimated 7 million people die of cancer every year; more than 2 million of AIDS. Up to 80 percent of these people may suffer severe pain, some for mont hs on end. Low and middle income countries – home to half of world‘s cancer patients and 95 percent of people with HIV – account for just 6 percent of worldwide use of morphine, the safe and inex pensive drug that is, according to WHO, absolutely necessary for the treatment of severe pain. Under int ernational drug control conventions and human rights treaties, countries are obliged to ensure availability of narcotic drugs for pain treatment. Yet many nations like India have failed to respond with appropriate policy steps, in spite of repeated reminders from UN d rug control bodies and the WHO. ―Failure of leadership is a chief cause of the pain treatment gap,‖ said Lohman. ―We know how to treat pain and the key drugs are cheap to produce and distribut e. What is lacking is the will and commitment to improve access. Governments must not stand by while people suffer.‖ common problems: * Many countries like India, do not recognize palliative care and pain treatment as priorities in health care, have no relevant policies, have never assessed the need for pain treatment or examined how well that need is met and have not examined the barriers to such treatment. * Narcotic drug control regulations or enforc ement practices in many countries impose unnecessary restrictions that limit access to morphine and other opioid pain relievers. They creat e excessively burdensome procedures for procurement, safekeeping, and prescription of these medications and sometimes discourage healt h care workers from prescribing narcotic drugs for fear of law enforcement scrutiny. * In many countries, medical and nursing school curricula do not include instruction on palliative care and pain treatment, meaning that many health care workers have inaccurate views of morphine and lack the knowledge and skills to treat pain adequately. These failures result in unnecessary suffering for people with moderate to severe pain and their families. For example: * An HIV-positive man in India has described to Human Rights Watch how he did not rec eive treatment for severe pain he experienced when he developed spinal tuberculosis in 2007. At the local AIDS clinic, where he was already receiving anti -ret roviral treatment, doctors put him on tuberculosis treatment and said that the pain would automatically disappear as the TB treatment progressed. But six months passed before the pain began to subside. * In September 2008, a woman in Colombia placed a classified ad in a loc al newspaper, saying: ―Cancer is killing us. Pain is killing me becaus e for several days I have been unable to find injectable morphine in any plac e. Please Mr. Secretary of Healt h, do not make us suffer any more.‖ The woman had not been able for several mont hs to get a steady supply of morphine to treat her daughter‘s pain because it was unavailable from pharmacies. * A doctor at a hospice in Kenya told Human Rights Watch in 2007: ―Physicians are afraid of morphine. … Doctors are so used to patients dying in pain…they think that this is how you must die. They are suspicious if you don‘t die this way and feel that y ou died prematurely.‖ Yet, several low and middle income count ries have made considerable progress in making pain treatment available. For example, Romania, Uganda, and Vietnam have all developed palliative care policies in recent years, have begun reworking problematic narcotics regulations and enforcement practices and have started training programs for doctors and nurses. ―Romania, Uganda, and Vietnam have convincingly shown that, with leaders hip, low and middle income countries can make important progress in closing the pain treatment gap,‖ said Lohman. ―India should follow their example.‖ Human Rights Watch calls on all countries to develop and carry out palliative care and pain treatment policies, if they have not already done so, to review their narc otics regulations to ensure that they do not interfere with medical use of morphine and ot her opioid medications, and ensure that palliative and pain treatment are included in training curricula for doctors and nurses. Is Financial Crisis the Reason for Your Back Pain? Leading Pain Doctor Says Talking, Walking, Laughing and Sex Can Help Is BSE to blame for your back pain? If you've been suffering from back, neck or shoulder pain lately, much of it could be a direct result of the financial crisis gripping the world, says pain specialist Dr Vasant Panchal, M.D., who offers suggestions to help you deal with that pain. They include talking, walking, laughing and sex. "The financial meltdown is causing millions to worry about losing their jobs, their homes and their retirement savings. And stress and tension are major causes of most common back and neck pain," says Dr. Panchal. "When you're tense, anxious, fearful or angry, your back, shoulder and neck muscles contract. And prolonged contraction of muscles as a result of stress and tension can cause pain severe enough to impair you. But there are strategies you can use to relie ve that pain," says Dr. Vasant Panchal He says the most effective physical activities are those that discharge pent-up energy and break a sweat. "Studies have shown that exercise reduces the production of chemicals in the body associated with both stress and depression, and it also stimulates the brain to produce neurotransmitters that can reduce pain and generate feelings of well-being, even euphoria." Dr. Vasant Panchal advises consulting a physician before beginning an exercise program. Here is some of the advice he is giving to his patients suffering from crisisinduced back pain. * Take a brisk walk * Go jogging * Take a bike ride * Swimming is excellent exercise. * Work out in a gym or exercise at home * Enjoy sex - In addition to the highly pleasurable benefits, studies have shown that the act of intimacy with a loved one can lower blood pressure and significantly reduce stress and anxiety TALKING IT OVER "Talking it over with someone you trust can work wonders," says Dr.Vasant Panchal. Each of our specific emotions has a muscle counterpart, a physical posture reflected in our body language or facial expressions, As fear or anxiety are dissipated during conversation, sustained muscle contractions -- and the pain they are causing -- are reduced." LAUGHTER "There are times when 'laughter is the best medicine' takes on renewed meaning, and this is one of them," says Dr. Panchal. "Research shows that laughter produces both physical and psychological dividends. It reduces stress and anxiety and increases tolerance to pain. Since, when we laugh, we stretch muscles, breathe faster, and send more oxygen to our tissues." PITFALLS TO AVOID WHEN YOU'RE STRESSED: Even though you might feel you deserve to overindulge, don't use the pressure of the financial crisis to suspend healthy habits: Excessive drinking, overeating, smoking or self-medicating can only make the situation worse. Even in "normal" times, millions of Indians suffer from back, neck and shoulder pain, says Dr. Panchal. "During this time of financial turmoil and uncertainty, millions more may be experiencing stress-related pain. If you're one of them, you should know that there are simple, effective -- and often enjoyable -- steps you can take to cope with it." Chronic Pain Harms The Brain People with unrelenting pain don't only suffer from the non-stop sensation of throbbing pain. They also have trouble sleeping, are often depressed, anxious and even have difficulty making simple decisions. Researchers found that in a healthy brain all the regions exist in a state of equilibrium. When one region is active, the others quiet down. But in people with chronic pain, a front region of the cortex mostly associated with emotion "never shuts up," The areas that are affected fail to deactivate when they should." They are stuck on full throttle, wearing out neurons and altering their connections to each other. This is the first demonstration of brain disturbances in chronic pain patients not directly related to the sensation of pain. Functional magnetic resonance imaging (fMRI) used to scan the brains of people with chronic low back pain and a group of pain-free volunteers while both groups were tracking a moving bar on a computer screen. The study showed the pain sufferers performed the task well b ut "at the expense of using their brain differently than the pain-free group," Dr Panchal said. When certain parts of the cortex were activated in the pain-free group, some ot hers were deactivated, maintaining a cooperative equilibrium between the regions . This equilibrium also is known as the resting state network of the brain. In the chronic pain group, however, one of the nodes of this network did not quiet down as it did in the pain-free subjects. This constant firing of neurons in these regions of th e brain could cause permanent damage, Dr Panchal said. "We know when neurons fire too much they may change their connections with other neurons and or even die because they can't sustain high activity for so long," he explained. 'If you are a chronic pain patient, you have pain 24 hours a day, seven days a week, every minute of your life," Dr Panchal said. " That permanent perception of pain in your brain makes these areas in your brain continuously active. This continuous dysfunction in the equilibrium of the brain can change the wiring forever and could hurt the brain." Wiring "may make it harder for you to make a decision or be in a good mood to get up in the morning. It could be that pain produces depression and the other reported abnormalities because it disturbs the balance of the brain as a whole." He said his findings show it is essential to study new approac hes to treat patients not just to control their pain but also to evaluat e and prevent the dysfunction that may be generated in the brain by the chronic pain.