Category Archives: Cancer Pain

Let’s Talk To An Inspirational Young Canadian Woman, Paula Orecklin, About CRPS, Sativex, Physiotherapy and Neuroplasticity

Featured Image provided by Paula Orecklin.

Sativex

Sativex is a cannabis-based mouth spray that is used for nerve pain relief in various painful conditions including cancer, complex regional pain syndrome (CRPS) and multiple sclerosis (MS).  It may also reduce spasticity, muscle spasms and sleep disturbances in MS patients (similar to the benefits of medical cannabis).

For more on Sativex, please see my blog post called ‘Medical Cannabis (Medical Marijuana) And Nerve Pain’.

A CRPS Patient, Paula Orecklin 

You may remember Paula Orecklin from my older blog post called ‘CRPS Video On CRPS By PARC’ (26/10/14).

I recently invited Paula to share more of her inspiring story including her challenges with severe chronic pain and her positive experiences with Sativex, physiotherapy and neuroplasticity work.  Paula immediately replied:

“I like being able to do something positive with all of this pain. If this can help other patients, I’m all over it. Sharing my story, talking to other people…I have to make something good out of all of this pain, you know? And I do have a lot of experience, I guess.”

Paula Orecklin (29) from Winnipeg, Manitoba, Canada, has complex regional pain syndrome (CRPS) that involves constant, severe pain in her right knee and lower right leg as a result of twisting her right ankle back in 2001 when she was only 13 years old. Thereafter, Paula couldn’t even put her right foot to the floor without triggering one vicious blast of pain after another, leaving her bedridden and literally screaming in bed for the next 2 weeks. Following this tragic and life-altering event, Paula had to resort to crutches (and later on, canes) for mobility and due to excess pain. She was wheelchair-dependent for a few months during 2004 – 2005 (caused by ‘blowing out her left knee’) and also for 3 years from 2013 to 2015 (due to unbearable pain leading to monthly ER visits for half a year).

Quoting from Paula’s 2013 YouTube (pre-Sativex treatment):

‘…Every single second, I am in pain, from my knee down to my toes. On my right leg, all there is is pain…there is always solid pain from my knee down. On top of that pain, I have other kinds, all different forms [of pain]…stabbing, shooting, burning, visceral, aching, throbbing…This is with all of my medications…’

See YouTube called ‘Paula Orecklin – UNE Patient Case Study – April 4, 2013’:

https://www.youtube.com/watch?v=_aAVOCGW5ac

Following 3 years in a wheelchair due to severe pain, Paula was offered Sativex for the first time in 2015.  In 2016, thanks to Sativex (and other medications), the support of a fantastic physiotherapist and neuroplasticity work with an excellent pain psychologist, Paula was finally able to trade in her wheelchair and crutches for walking canes!

unnamed-3.jpg

Image provided by Paula Orecklin.

However, despite Sativex, Paula still has constant, severe pain every single second of her life. In her words:

[CRPS] still has all sorts of horrible kinds of pain [despite Sativex]. I can be doing well and suddenly ‘a giant poker’ has been stabbed through my leg. I was at a meeting on Saturday and in the middle of it, my foot set on fire. I’m always in pain and then on top of that, there are all sorts of different kinds of pain that come on extraordinarily suddenly. What I said in the video [3 – 4 years ago] is exactly what [still] happens today.’

Thus, while Sativex does not eliminate Paula’s base level of constant and severe pain nor her initial sudden pain attacks from occurring, it can block the repetitive flare cycles. By preventing these ongoing vicious pain cycles in 5 minutes, Sativex enabled Paula to finally undergo physiotherapy to improve her function and mobility. In Paula’s words:

“…Sativex is good at keeping the huge flare cycles down… I’m doing better functionally, so much better. But it doesn’t really work on my constant level of pain.”

Before Sativex, Paula suffered from out-of-control pain levels due to sudden and repetitive waves of pain spikes that would combine with her initial pain spike. One pain spike would lead to another pain spike, and on and on it went. This vicious and ongoing pain spike cycle often led to extremely high pain levels until finally her other medications kicked in.

Paula started using Sativex sublingual mouth spray 2 years ago. While it ‘tastes pretty disgusting, like spraying mosquito repellent into your mouth’, Paula said that she was doing very well as Sativex helps her manage her pain levels better. Being a mouth spray, Sativex has the advantage of gaining faster access directly into the blood capillaries via diffusion through the tissues under the tongue.

Paula has a prescription for a refill bottle of Sativex every 8 days. Sativex is not covered by public healthcare where Paula lives in Manitoba, and at CDN256.05 a bottle, Sativex is not cheap. Even though Paula’s private insurance helps defray most of the cost, Paula is still left out-of-pocket CDN60 per bottle. Using up to 12 sprays a day (and even up to 15 sprays on very painful days), a bottle of 90 sprays can go very quickly.

Despite its costs, Paula finds Sativex’s ability to block the repetitive flare cycles worthwhile. For the first time in her life, Paula has finally found a way to stop the vicious and ongoing cycles of pain spikes before they even start. This enables Paula to do physiotherapy and neuroplasticity training despite ongoing, unrelenting and severe pain. For example, she is now able walk between 1 to 2.4 miles with the aid of 2 walking canes.

Paula does not have any side effects from Sativex other than feeling ‘fuzzy everywhere’ on ‘really bad days’ when more than 9 – 10 sprays and increased hydromorph IR are required.

While Paula has tried medical marijuana (medical cannabis), she found it ineffective against her painful flare-ups. In contrast, Sativex is able to stop her pain flares in 5 minutes hence preventing a vicious circle of painful flare-ups. Furthermore, because Sativex looks like a regular inhaler, it is easier for Paula to be seen using Sativex than, say, medical marijuana. In other words, Sativex is not associated with the social stigma associated with using medical marijuana for pain management.

[I’ve gone from being] forced … to leave university, to carrying the Olympic torch [see photo below], to helping found a local CRPS support group, to creating my own Disability holiday….that after 15 years I …still [attend]. I’m going to celebrate it again this March…after 16 years I’m actually going somewhere now.  I’ve managed to make as much of a life out of my circumstances as I can.”

unnamed-1.jpg

Image provided by Paula Orecklin.

On behalf of all Canadians with chronic pain, Paula was formally honoured and selected to be an Olympic torchbearer for the 2010 Vancouver Olympic Winter Games. Paula had to practice walking and holding up one of her old crutches (in lieu of the Olympic torch) for 6 – 7 months beforehand.

One very early morning on a cold wintry day at -30C in January 2010 in Virden, Manitoba, Paula successfully fulfilled her pledge to carry the Olympic torch for 500 meters without mobility aids! Needless to say, being chosen as an Olympic torchbearer for the 2010 Winter Olympics to represent all Canadians living with chronic pain was one of Paula’s proudest achievements.

Thanks to a multi-disciplinary approach to CRPS that involved:

  • Sativex treatment;
  • Hydromorph IR and other conventional pain medication;
  • Physiotherapy;
  • Neuroplasticity work (with her pain psychologist); and
  • Various other pain strategies,

Sativex made a huge difference to Paula’s quality of life by opening the door for the first time to physiotherapy, regular exercise and neuroplasticity work, leading to a dramatic improvement in her CRPS symptoms including repetitive painful flares.

In her own words:

‘I’ve found in the past few months that not only have I been able to do more, be out and see people, exercise and still not fall apart, but I’ve also been increasing my tolerance to everything. I’ve actually been using less breakthrough medication, both Sativex and my hydromorph IR. I’m genuinely doing better. I think I’m down to about a bottle every 13 days right now.’

‘Without Sativex, I would never have been able to get to where I am today.

The neuroplasticity would have helped with my own depression due to pain and my understanding of pain and just generally improved my mental state.

But no real improvement physically would have been possible without Sativex.’

‘I’m doing better than I have in a very long time. Sativex is absolutely critical to this upswing. With Sativex, I can give myself medication with every flare of pain. It kicks in in only 5 minutes. The pain doesn’t have a chance to build on itself but is cut down quickly. I can also give myself another spray in 5 minutes if the pain keeps getting worse or doesn’t go down enough.

I can take up to 12 sprays a day and there aren’t really any side effects. I can get a kind of drugged feeling, but it’s not a high nor is it particularly strong. I have to be careful to spray under different parts of my tongue (ie sometimes my tongue’s left side, sometimes up front in the middle, sometimes on the right) so I don’t get wounds under my tongue. However I’ve never had a single one develop. It’ll sting a little when I’ve used a ton of sprays in one spot, but that’s just a reminder to be sure to move it around. And this might be of clinical significance since my skin is very delicate and develops wounds from my CRPS. ….

I mean, the drug is no magical cure, but it’s been absolutely essential to my progress. Without it, I might have gotten some psychological benefit from the neuroplasticity, but I definitely couldn’t be able to move any better. I’d never have ever been in a place where I could work with my physiotherapist. Before Sativex, I was in my wheelchair for nearly everything. I was finally able to walk again because of [Sativex].’

‘I’ve been working with an amazing physiotherapist since this spring. I was finally able to start walking, but was doing it so unevenly I was hurting my good side’s hip. She’s made a big impact on getting me moving.’

‘…I just came home from the gym, did really well I was powering around the track, listening to music, just … moving. And that kind of feels like a medical miracle. I was in such horrible shape for so long, and it just feels so good. And painful of course, but that’s just a given.’ 

‘I’m doing better now than I have in so many years … I’ve never in my life been able to have sustained progress like this.  I’m still disabled, and there are so many things I still can’t do, but that’s not really what I’m concerned with right now. I’m just happy to see where I am now.’ 

‘Sativex has been really important in my life over the past two years, but I just don’t want it to come off like it’s a … well, miracle. It isn’t. It’s made a massive impact on my life, but I’d say that my massive improvement over the past year is only a third down to the spray.’

Paula added, ‘None of anything would have been possible without hydromorphone IR, nor the rest of my medications. Nothing would be possible without my pain specialist at the pain clinic. It really has been a team effort, and that’s not even counting my other physicians, or the essential support network I have. My parents support me 100%, and that’s both emotional and financial. My mother, in particular, is my caregiver and is a huge part of my life. I’m very lucky to have friends who understand and care too. My best friend’s support over the years has meant so much to me too.’ 

‘Now none of those other things helps in the same ways Sativex does. Without it, I wouldn’t be able to move forward and make sustained progress for what is literally the first time in my life since hurting my leg. I’d never managed to go forward at all, ever; plateauing was all I could hope for. But I still feel like all of those other things are coming together to really help me in way that Sativex alone couldn’t. In fact, what’s really amazing is that I’m actually not using as much Sativex as I used to. Everything’s coming together much better than I ever could have expected. My leg is actually dealing with things better, not needing the same amount of as-needed medications. For the first time too, I’m actually finding other non-medicinal things like heat packs are actually helping. Before, it was just way worse when I didn’t have them, but it didn’t lower the pain exactly. So you can say it is kind of a holistic thing – but one that needed Sativex to open the door to it, if that makes sense…’

Having said all of the above, Paula emphasized:

‘[I am] actually never without pain … Sativex helps to stop the vicious circle of escalating pain cycles in 5 minutes.’

‘…I’m still in rough shape. But when that rough shape is so much better than the rougher shape I was in [before Sativex]…

‘[CRPS] is still incredibly disabling. But when you start so low, every few inches up makes a big difference.

Paula’s positive experience with Sativex may offer hope and inspiration to other pain patients to also add Sativex into their overall pain management therapy.

Thank you, Paula, for sharing your beautiful story with us! Despite living with constant, severe pain, your strength and inner beauty never cease to amaze me! People like you are the inspiration and main driving force behind this blog.

With positive thoughts coming your way from everywhere and everyone,

Sabina Walker

Blogger, Pain Matters

Patching up Pain with a Lidocaine 5% Patch

Dear Pain Matters readers,

Treatment via a lidocaine 5% patch may offer significant pain relief for patients including cancer patients with focal nerve pain.

Specifically, patients with severe and localised nerve pain including one of the following painful conditions may benefit from a lidocaine 5% patch that topically delivers lidocaine:

  • Postherpetic neuralgia and herpes zoster (shingles);
  • Non-diabetic and diabetic peripheral neuropathy;
  • Trigeminal (orofacial) neuropathic pain;
  • Erythromelalgia;
  • Chronic low back pain (Hines et al, 2002);
  • Post-surgical neuropathic pain (e.g. following surgery for cancer or otherwise); and
  • Neuropathic pain directly attributable to cancer.

Lidocaine works by blocking sodium channels including Nav1.7 that underlie many nerve pain conditions (and other mechanisms).  The release of very small amounts of lidocaine transdermally via the patch ensures that motor and cardiac functions remain unaffected.

While topical lidocaine patches leads to pain relief in 29%-80% of treated patients, likely via small-fiber block, it is not clear why lidocaine patches may work better in some patients than in others (Krumova et al, 2012).

The topical lidocaine patch, measuring 10 cm X 14 cm, should only be applied on top of unbroken skin and where the pain is the greatest.  Patches should only be used by patients who are not allergic to local anaesthetics including lidocaine and who are not sensitive to the adhesive material itself.

The recommended maximum daily dose is 3 patches worn simultaneously for 12 hours at a time.  Since the lidocaine patch can only be worn for 12 hours at a time each day, other pain medications may be necessary, especially during sleep.

A Young Patient With Episodic Erythromelalgia In Both Feet

A 15-year old Caucasian girl who suffered disabling pain during episodes of erythromelalgia in both feet derived complete pain relief almost immediately after applying lidocaine 5% patches to the top of both of her feet, both at rest and during almost normal levels of activity.  

m_dce10009f2-3.png

Post-lidocaine patch treatment, the young patient was able to run around the track at school, play soccer, return to her physical education class, march in the school band and walk around the shopping mall for almost an hour.  As long as she did not overdo her activities, she was able to obtain 100% relief during the 12 hours of lidocaine patch use, plus another 2-3 hours after patch removal.  The patient slept without the patches.

Whilst offering complete local pain relief and no side effects, the lidocaine patch was unable to prevent the other symptoms of erythromelalgia from occurring including bright red skin and over-heated feet following physical exertion.

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(Davis & Sandroni, 2002, including both images).

Two (2) Patients With Neuropathic Pain Syndrome     

A 74-Year Old Female Patient With Herpes Zoster (Shingles)

Despite prompt treatment for a herpes zoster skin rash, a 74-year old woman developed stabbing and burning pain in her rash-affected area.  The patient was offered 2 lidocaine patches daily to cover the painful region.  Within 4 weeks treatment, the patient obtained 75% relief from pain caused by her herpes zoster skin rash.  Most of her systemic pain medications were stopped.

A 56-Year Old Male Patient With Severe Neuropathic Pain Syndrome Following Microsurgery For A Neuroma in Right Foot 

A 56-year old man suffered severe nerve pain shortly after microsurgery to his right foot due to an interdigital neuroma.  His painful symptoms included severe burning pain, mechanical hyperalgesia and allodynia, together with other symptoms.  As a result, he could no longer work, was unable to wear socks and shoes (only sandals) and withdrew from his family and friends.

After applying half of a lidocaine 5% patch daily onto his painful skin region, the patient reported positive results.  After 8 weeks of lidocaine patch treatment, the patient enjoyed an 80% reduction in overall pain levels and consequently returned to work.  There were no side effects and the patients was able to stop all other analgesics (Hans et al, 2010).

Trigeminal (Orofacial) Neuropathic Pain And Lidocaine Patch Treatment

A British study revealed that lidocaine 5% patch treatment led to improved pain levels in 12 of 14 trigeminal pain patients including oral surgery patients.  Nine (9) of the 12 patients were able to reduce or stop their intake of other pain medications.  Given that the majority (12/14) patients with trigeminal nerve pain benefited from lidocaine 5% patch treatment, further studies are warranted (Khawaja et al, 2013).

Cancer Patients And Lidocaine Patch Treatment

A large Australian study in a comprehensive cancer centre revealed that lidocaine 5% patch treatment had a ‘potent analgesic effect’ in 24 of 95 (25%) patients while another 23 patients (24%) reported a ‘partial effect’.  Given that almost half (47/95, or 49%) of all cancer patients with nerve pain benefited from lidocaine 5% patch treatment, further research is warranted (Fleming and O’Connor, 2009).

Current Study Involving Lidocaine Patch for Lower Limb Amputation Pain

A Belgium-based trial is currently recruiting up to 20 patients with pain following above- or below-knee amputation to assess the effectiveness of lidocaine patch treatment for peripherally-mediated phantom limb pain and/or stump scar hyperalgesia (Hatem, 2016).  Stay tuned for updates…

Summary

While lidocaine 5% patch treatment is expensive and there is a small risk of a skin rash, many patients with focal nerve pain obtain significant pain relief from the lidocaine 5% patch, a targeted peripheral analgesic that is non-addictive and safe for long-term use.  

Now that’s a good way to patch up pain!

Sabina Walker

Blogger, Pain Matters

REFERENCES

(1) Davis, Mark D P; Sandroni, Paola. Lidocaine Patch for Pain of Erythromelalgia; Arch Dermatol. Jan 2002;138(1):17-19

doi:10.1001/archderm.138.1.17

http://jamanetwork.com/journals/jamadermatology/fullarticle/478622

(2) Fleming JA, O’Connor BD.

Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre.

(Utilisation des timbres de lidocaïne pour la douleur neuropathique dans un centre d’oncologie)

Pain Research & Management : The Journal of the Canadian Pain Society. 2009;14(5):381-388

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779156/#!po=28.7879

(3) Hans G, Robert D, Verhulst J, Vercauteren M. Lidocaine 5% patch for localized neuropathic pain: progress for the patient, a new approach for the physician. Clinical pharmacology : advances and applications. 2010;2:65-70

doi: 10.2147/CPAA.S9795

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262358/

(4) Hines R, Keaney D, Moskowitz MH, Prakken S. Use of Lidocaine Patch 5% for Chronic Low Back Pain: A Report of Four Cases. Pain Med 2002; 3 (4): 361-365

doi: 10.1046/j.1526-4637.2002.02051.x

https://academic.oup.com/painmedicine/article-lookup/doi/10.1046/j.1526-4637.2002.02051.x

(5) Khawaja N, Yilmaz Z, Renton T. Case studies illustrating the management of trigeminal neuropathic pain using topical 5% lidocaine plasters. British Journal of Pain. 2013;7(2):107-113.

doi:10.1177/2049463713483459

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590123/#!po=23.6842

(6) Hatem, Samar; A Trial of Lidocaine Patch for Lower Limb Amputation Pain (Trial ongoing since 2016); Brugmann University Hospital

https://clinicaltrials.gov/ct2/show/study/NCT02696720?view=results

(7) Krumova EK1, Zeller M, Westermann A, Maier C. Lidocaine patch (5%) produces a selective, but incomplete block of Aδ and C fibers. Pain. 2012 Feb;153(2):273-80.

doi: 10.1016/j.pain.2011.08.020.

https://www.ncbi.nlm.nih.gov/pubmed/21995882

(8) Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open-label study. Clin J Pain. 2000 Sep;16(3):205-8.

https://www.ncbi.nlm.nih.gov/pubmed/11014393

(9) Many Other Lidocaine Patch/Pain Studies Can Be Found Here:

http://www.druglib.com/druginfo/lidoderm/abstracts/

Music Therapy and Chronic Pain

Dear Pain Matters blog readers,

Music therapy took Melody Gardot from the aftermath of her bicycle/Jeep accident (that lead to severe injuries and chronic pain) and helped her become an international jazz musician.

https://painmatters.wordpress.com/2016/08/13/melody-gardot-jazz-singer-songwriter-musician-and-music-therapy-for-her-chronic-pain-following-a-bicyclejeep-accident/

This blog post will offer some of the science behind music therapy and its potential benefits on chronic pain.

For music to offer therapeutic benefits, a patient has to enjoy music in the first place.  Furthermore, patients need to listen to, or play/sing, their favourite music before music can improve pain tolerance and reduce perceived pain intensity.

The ability of some music to express positive emotions as well as deeply evoke these same emotions in the listener (via ‘entrainment’, or resonance) may also contribute to reduced pain perception and increased pain tolerance.

When patients are exposed to their favourite ‘up-lifting’, emotionally-engaging music, this music can help displace negative emotions and feelings including fear, anxiety, depression, loneliness and distress due to pain, and replace them with positive emotions including happiness and joy, while also empowering patients to feel more in control over their pain levels.

Certain music played pre- and post-operatively, as well as during surgery, may result in less sedation/anesthesia being required during an operation, as well as reduced opioid medication, post-surgery.  These patients often report lower pain intensity levels, post-operation.  Pre-surgery, patients who listened to their favourite music tend to feel less anxiety and stress, and instead, feel more physically relaxed.

In cancer patients, music therapy can decrease chemotherapy-induced nausea and vomiting.

If welcomed by the patients, music therapy can be a cost-effective adjunct for patients including children in dental, paediatrics, surgery, anaesthesia, palliative care and other clinical settings.  After all, music is safe, natural and non-invasive, with nil adverse effects.

Music Therapy for Chronic Pain:

Music therapy for chronic pain including cancer pain can include:

  • Listening; and
  • Participating via
    • Group singing/choir – that releases oxytocin; and
    • Playing/learning a musical instrument (including a wind instrument; e.g. saxophone); and
  • Other music therapy techniques (Magill, 2001).

The best results are obtained when the selected slow music is personalised to the patients’ unique and personal preferences.

Research into music therapy for many painful medical conditions is underway worldwide including at The Louis Armstrong Department of Music Therapy, Mount Sinai Beth Israel, New York.

http://www.wehealny.org/services/bi_musictherapy/readings.html

Neuroscientist and musician, Professor Daniel Levitin, Department of Psychology, McGill University, Montreal, is another leading researcher on the benefits of music therapy.

https://www.mcgill.ca/psychology/daniel-j-levitin

http://daniellevitin.com/publicpage/in-the-news/in-print/

Physiological Effects of Musical Rhythm:

Music therapy that involves music with a slow tempo but strong (positive) emotions can reduce heart rate, blood pressure and body temperature, as well as increase heart rate variability, plus exert other physiological responses controlled by the brainstem.  This can result in reduced pain levels, stress and anxiety.

Slow music with 10-second repetitive cycles/waves may have a particularly calming effect on its listeners.  It is possible that such music may match the control rhythm of the cardiovascular system including the brain’s natural 10-second waves/cycles of blood pressure control (to regulate blood pressure, heart rate, etc).

The brain monitors blood pressure measurements after each heartbeat, and it sends signals to control blood pressure in the blood vessels via 2 separate nerves operating at different speeds, resulting in signals that are ‘out of phase’ every 9 of 10 seconds, and signals that are ‘in phase’ every 1 of 10 seconds (Professor Peter Sleight et al, University of Oxford).

‘Entrainment’ (or resonance) of the body’s natural 10-second waves of blood pressure control may be amplified via exposure to slow music that also has a 10-second repetitive cycle.

Examples of slow music with 10-second repetitive cycles/waves include music by Verdi, the arias of Puccini’s opera Turandot and slow movements of Beethoven’s Ninth Symphony.

Interestingly, certain prayers may also have a calming effect including the prayer Ave Maria that has a 10-second rhythm when read out in Latin 50 times (as is the norm in some Italian Catholic church services) (Professor Peter Sleight et al, University of Oxford).

Listening to music that has a slow beat of only 50-60 beats per minute can cause the listener’s heart rate to gradually synchronise with this slower tempo (via ‘entrainment’).  A song with a slower tempo that is longer than 5 minutes long may lead to a deeper sense of relaxation than songs that are shorter than 5 minutes.  This is because a body may take around 5 minutes before is is fully entrained with an external rhythm.  

This was confirmed by a study that found that out of 15 songs tested, ‘Weightless’ (an 8 minute-track by Marconi Union) had the most profound effects on relaxation.  This song resulted in reductions in overall anxiety by 65% and physiological resting rates by 35% (Gerges, 2011; Gillett, 2016).  Whilst not tested in this study, these positive results could have spill-on effects on pain levels.    

Physiological Effects of Music on Neurotransmitters, Cortisol and the Immune System:

Neurotransmitters including endorphins (the brain’s natural opioid/morphine) and oxytocin may be released during exposure to preferred music.  These neurotransmitters help reduce pain levels and induce analgesia as well as decrease anxiety and stress.

Music can reduce cortisol levels in the bloodstream (a sign of reduced stress).

Researchers discovered that singing certain slow, sad songs can lead to increased s-IgA, an immunoglobulin that enhances overall immunity.

Prolactin may be released via tears of sorrow during ‘sad music’.  Increased prolactin can have an overall calming and consoling effect….which is why a good cry can sometimes be a good thing.

Summary:

Music therapy, in particular, exposure to slow music with certain rhythms (e.g. slow music with 10-second rhythms/cycles/waves) can reduce overall pain levels. In part, this may be due to selected musical rhythms having a beneficial effect on the heart and blood vessels.

Sabina Walker

“Sedare dolorem divinum opus est”

“It is divine to alleviate pain”

Galen, 130-200 C.E.

REFERENCES

Media Releases:

For English readers:

(1A) Music and pain relief

Jeanette Bicknell

Psychology Today (1 Nov 2011)

https://www.psychologytoday.com/blog/why-music-moves-us/201111/music-and-pain-relief

(1B) How music can help relieve chronic pain

Don Knox

The Conversation (10 September, 2015)

http://theconversation.com/how-music-can-help-relieve-chronic-pain-47302

(1C) The doctor will sing to you now: Music therapy and the coming rise of minstrel medicine

Dr. James Aw

National Post (13/07/02)

http://daniellevitin.com/levitinlab/printmedia/2013-07-02-National-Post.pdf

(1D) Why joining a choir is the easiest way to make yourself happier

Stacy Horn

Slate (July 25, 2013)

http://daniellevitin.com/levitinlab/articles/2013-08-12_Slate.pdf

(1E) Want to relax? Listen to Verdi, scientists say

Steve Connor

The Independent (9 June 2015)

http://www.independent.co.uk/news/science/want-to-relax-listen-to-verdi-scientists-say

10306136.html

 

(1F) Music to mitigate pain

18 August 2016

http://www.thehindu.com/features/metroplus/music-to-mitigate-pain/article8999737.ece

(1G) Gillett, Rachel. Science Says This Song Can Reduce Your Anxiety In Less Than 10 Minutes. Business Insider Australia (7 Nov 2016).

https://www.businessinsider.com.au/the-song-that-could-reduce-your-anxiety-in-less-than-10-minutes-2016-11?r=US&IR=T

(1H) David, Gerges. Just Don’t Play It While You’re Driving! Warning Over ‘Most Relaxing Song Ever Created’.  Daily Mail Australia (18/10/2011)

http://www.dailymail.co.uk/news/article-2049948/Most-relaxing-song-UK-band-Boffins.html

For German readers:

(2A) Schmerzen lindern mit Musiktherapie

Alexandra Springler

MedMix (9 October 2015)

http://www.medmix.at/schmerzen-lindern-mit-musiktherapie/

(2B) Musiktherapie in der Behandlung chronischer Schmerzen

Bacher, B.

14. Schmerztherapeuten-Treffen, Universitätsklinikum Freiburg (20 November 2015)

https://www.uniklinik-freiburg.de/fileadmin/mediapool/09_zentren/schmerzz/st2015/MusiktherapieBehandlungChronischerSchmerzenBacher2015-11-20.pdf

Peer-reviewed papers:

(3A) Bernatzky, G, Presch, M, Anderson, M & Panksepp, J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neuroscience and Biobehavioral Reviews (Oct 2011), 35(9), 1989-99.

DOI: 10.1016/j.neubiorev.2011.06.005

http://www.ncbi.nlm.nih.gov/pubmed/21704068

(3B) Knox, D, Beveridge, S, Mitchell, L & MacDonald, R. Acoustic analysis and mood classification of pain-relieving music. Journal of the Acoustical Society of America (Sept 2011), 130(3), 1673-82.

DOI: 10.1121/1.3621029

http://www.ncbi.nlm.nih.gov/pubmed/21895104

(3C) Magill, L. The use of music therapy to address the suffering in advanced cancer pain. Journal of Palliative Care (2001), 17(3), 167-172.

http://www.ncbi.nlm.nih.gov/pubmed/11816757

(3D) Young, Emma. Healing rhythms. New Scientist (12 September 2015), 227(3038), 36–9.

http://www.sciencedirect.com/science/article/pii/S0262407915311775

(3E) Chanda, ML & Levitin, DJ. The neurochemistry of music. Trends in Cognitive Sciences (April 2013), 17(4), 179-93.

http://www.cell.com/trends/cognitive-sciences/abstract/S1364-6613(13)00049-1

An Australian Woman With Chronic Back Pain, A Beautiful Neurosurgeon and A 3D-Printed Spine Implant (Plus Other Patients With Custom 3D-Printed Body Parts)

Source of Featured Image:

RMIT University

https://www.rmit.edu.au/news/all-news/2015/august/australias-first-3d-printed-spine-implant/

Dear Pain Matters blog readers,

Is this the title of a new science fiction novel??

“An Australian Woman With Chronic Back Pain, A Beautiful (Neurosurgeon’s) Mind and A 3D-Printed Spine Implant”

No, this is not science fiction….This really did happen!

Welcome to the futuristic world of 3D-printed body parts, and its potential role in reducing chronic pain!

Happily, for Amanda Gorvin, the future is now!

Amanda (38) had suffered persistent and crippling lower back pain for more than 30 years.  Amanda suffered shooting pains and countless sleepless nights due to a deformed lower back vertebra.  She had spent an entire adult life on antiinflammatories, ibuprofen, Nurofen, cortisone injections and physiotherapy.  Amanda’s lower back pain had affected her quality of sleep, resulting in only 3-4 hours sleep a night, as well as lethargy and exhaustion during her waking hours.  By now, her lower back pain adversely affected her social, sporting and sex life.  She was unable to dress herself without exerting a huge and painful effort.  As a result of her lower back pain that limited her physical activity, Amanda gained 30 kg in 5 years.

She finally had enough of her ‘bones rubbing’ in her lower back, causing excruciating pain every time she moved.  One night at 2AM, she dragged herself out of bed and crawled into the kitchen, crying out in pain.  At a loss what to do next, Amanda told her neurosurgeon, Dr Marc Coughlan, several days later, “Marc, I can’t do this anymore.”

Her neurosurgeon replied, “I’ve got this new thing.”

Dr Marc Coughlan and another surgeon collaborated with 3D implant company, Anatomics, and a team of scientists and engineers at RMIT University (Melbourne) to custom design a 3D-printed spinal implant for Amanda Gorvin.  Few international surgeons have done this procedure, and Dr Marc Coughan was the first Australian surgeon to attempt this.  His patient, Amanda, was Australia’s first patient to agree to this.

After explaining the risks to Amanda, Dr Marc Coughlan operated on 3 April 2015 to insert a custom 3D-printed spinal implant into her lower back.

In Dr Coughlan’s words (quoting):

“The beautiful thing when we put the implant in was that it felt like a key going into a lock.  I could actually feel it click into place.  It was so intrinsically stable, it was like a dream for a spinal surgeon.”   

marc 201x214

Dr Marc Coughlan, MBChB, FRACS, FCS

Source:

http://www.coastalneurosurgery.com.au/AboutUs.asp

After her 3D-printed spine implant operation, Amanda stated (quoting):

“I was back at work four weeks after the operation, back in the gym after six weeks,” she says. “I was breathing better, my mind was clearer, I felt lighter. It’s incredible how much influence the spine has on the rest of the body. I remember that pre-surgical pain and now I ­haven’t got one per cent of it. It’s nothing short of miraculous.” As she speaks, Gorvin becomes emotional and reaches for a tissue. “This has absolutely changed my life,” she says.”

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Amanda Gorvin

Source:

http://www.theaustralian.com.au/news/special-features/d-printing-human-organs-it-suddenly-doesnt-seem-so-far-off/story-fnolgd60-1227482157233

Results like this simply speak for themselves….

Amanda has Dr Marc Coughlan, Neurosurgeon, to thank (for his beautiful mind).  Of course, the idea would not have materialized without the help of the 3D-printing team led by RMIT University Professor Milan Brandt and key staff at Anatomics.  The custom 3D-printed spinal implant literally erased Amanda’s lower back pain (that she had suffered for more than 3 decades).

OTHER PATIENTS WITH CUSTOM 3D-PRINTED BODY PARTS INCLUDING A TITANIUM HEEL, A PLASTIC SKULL AND A TITANIUM JAW JOINT

Len Chandler (71), recipient of a 3D-printed titanium heel:

A 71-year old former builder from Rutherglen, Victoria, Australia, Len Chandler, was facing amputation of his right leg below the knee due to rare cartilage cancer in his right heel.

Luckily, a surgically-implanted 3D-printed titanium heel (the first of its kind in the world) changed his fate for the better.

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Len Chandler (above), together with replicas of his 3D-printed heel

Source:

China Daily Asia

http://www.chinadailyasia.com/asiaweekly/2015-01/16/content_15214917.html

After surgery for his 3D-printed heel implant, he stated (quoting):

“I’ve got no irritation or pain or anything from that.  It just fits perfect, I couldn’t asked for anything better.”

A 22-year old Dutch woman, recipient of a 3D-printed near-entire plastic skull:

A Dutch woman (22) suffered from severe headaches, loss of vision and compromised motor coordination as a result of abnormal skull thickening.  Without drastic intervention, she was facing further brain function loss, ongoing severe headaches and an early death.

Her doctors surgically implanted a near-entire plastic skull, custom 3D-printed by Anatomics.  The operation was a huge success.  Three (3) months after her surgery, the woman’s severe headaches have disappeared and she fully regained her vision.

140327-science-3d-printed-skull_e8f32032da2f37a65e83ba184442e287.nbcnews-ux-600-480

Above, 3D-printed plastic skull

Source:

http://www.nbcnews.com/science/science-news/medical-first-3-d-printed-skull-successfully-implanted-woman-n65576

Richard Stratton (32), recipient of a 3D-printed titanium jaw joint:

Richard Stratton, a 32-year old Melbourne-based psychologist, received a 3D-printed prosthetic jaw implant on 23 May, 2015.

Part of his jaw had never grown properly ever since he was knocked in the jaw during childhood.  In fact, he was missing part of his jawbone including the left condyle (part of the temporomandibular joint, or TMJ).  This caused significant strain on the right side of his jaw and also left him with a crooked smile.

In recent years, he suffered sharp pain while moving his jaw, biting, chewing and eating and he also had painful headaches at night.  He was unable to fully open his mouth.

Dr George Dimitroulis (Oral and Maxillofacial Surgeon, St Vincent’s Hospital, Melbourne) designed a prosthetic jaw that included a 3D-printed titanium jaw joint implant and a 3D-printed plastic jaw joint (in collaboration with Dr Ackland and team, Department of Mechanical Engineering, The University of Melbourne).  The entire process from the initial design stage to the 5-hour operation took 3 years.

The plastic jaw TMJ is (likely) the first 3D-printed jaw joint in the world.

Quoting Dr Dimitroulis:

“The excitement was unbearable I think, just at the last minute we thought it just wasn’t going to fit in but it just slid in nicely.”

“It just clipped in.”

He has reason to be “very proud” that 3 years of hard work had resulted in such positive results.

7b57e551f0f7fcf6b2bcb1e2c5b5faa857feaf7cf02a1813a3445495ac4c.jpg

Above, Dr George Dimitroulis (Oral and Maxillofacial Surgeon, St Vincent Health)

Source:

https://pursuit.unimelb.edu.au/articles/the-jaws-of-life

One month after the post-surgery pain and swelling (that lasted a few days) subsided, Richard Stratton said he was able to open his mouth wider than before the surgery.  Several months later, he was chewing on both sides and eating normally.  His painful headaches at night also disappeared.

For more details, please view video by The University of Melbourne called:

‘When BioMechanics Colllides with Medicine’

Quoting Richard Stratton (several months after his operation):

“The joint has been working really, really well. It really has improved my quality of life.”

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Above, Richard Stratton’s 3D-printed titanium jaw part (attached to a 3D printed version of his skull)

images.jpeg

Above, ‘Before Surgery’ (left) and ‘After Surgery’ – with surgical scar visible on jawline (right)

Source:

http://www.abc.net.au/news/2015-06-20/melbourne-man-receives-titanium-3d-printed-prosthetic-jaw/6536788

Patients with severe TMJ pain caused by jaw joint osteoarthritis, cancer, trauma or congenital abnormalities may benefit from 3D-printed titanium jaw joint implants.  Such implants may lead to complete restoration of jaw function plus significantly reduced/nil jaw pain.

SUMMARY

Here’s to the future that may include 3D-printed body implants to help reduce chronic pain!  Happily, for some, the future is already here!

Sabina Walker

REFERENCES

(1A) The Shape of Things to Come

Richard Guilliatt; The Australian (The Weekend Magazine) (pages 10-14); August 15-16, 2015

http://www.theaustralian.com.au/news/special-features/d-printing-human-organs-it-suddenly-doesnt-seem-so-far-off/story-fnolgd60-1227482157233

(1B) Surgeons Print Out 3-D Body Implant

Richard Guilliatt; The Australian (page 3); August 15-16, 2015

http://www.theaustralian.com.au/news/health-science/surgeons-print-out-3d-body-implant-for-spinal-operation/story-e6frg8y6-1227484209363

(2) Joint Effort Produces Australia’s First 3D Printed Spine Implant

RMIT University; August 17, 2015

https://www.rmit.edu.au/news/all-news/2015/august/australias-first-3d-printed-spine-implant/

(3) Anatomics

http://www.anatomics.com/company/news/

(4A) 3D Printing: Rare Cancer Sufferer, Len Chandler, Back On His Feet After Receiving Titanium Printed Heel
Lisa Tucker; ABC News; 22 Oct 2014

http://www.abc.net.au/news/2014-10-21/rare-cancer-sufferer-receives-3d-printed-heel/5830432

(4B) Close to the Bone
Karl Wilson (in Sydney, Australia); China Daily Asia; 16 January, 2015

http://www.chinadailyasia.com/asiaweekly/2015-01/16/content_15214917.html

(4C) World First Heel Implant at St Vincent’s Private Hospital Melbourne 7 News

(5) Medical First: 3-D Printed Skull Successfully Implanted in Woman
James Eng; NBC News; 27 March 2014

http://www.nbcnews.com/science/science-news/medical-first-3-d-printed-skull-successfully-implanted-woman-n65576

 

(6A) The Jaws of Life

Val McFarlane; The University of Melbourne; 24 September 2015

https://pursuit.unimelb.edu.au/articles/the-jaws-of-life

(6B) Titanium, 3D-Printed Prosthetic Jaw Implanted in Melbourne Man in Australian First Surgery

Stephanie Ferrier; ABC News; 22 Jun 2015

http://www.abc.net.au/news/2015-06-20/melbourne-man-receives-titanium-3d-printed-prosthetic-jaw/6536788

Nabilone for Chronic Pain Including Nerve Pain (eg CRPS)

Dear Pain Matters blog readers,

Dr Mark Ware, McGill University in Montreal, reported that Nabilone (‘Cesamet’), an oral synthetic cannabinoid, may offer some pain relief in both cancer and non cancer pain.  

Specifically, Nabilone may help alleviate painful symptoms in patients with:

– Nerve pain (e.g. complex regional pain syndrome, CRPS);

– Multiple sclerosis;

– Fibromyalgia; 

– Other chronic non cancer pain (eg postoperative or traumatic pain, arthritis, Crohn’s disease, interstitial cystitis, HIV-associated myopathy, post-polio syndrome, idiopathic inguinal pain, and chronic headaches); and

– Cancer pain.

Dr May Ong-Lam reported that in 10 patients with refractory CRPS, Nabilone treatment resulted in up to 60% pain reduction.  Opioids and other pain medication were no longer required by 7 patients following Nabilone therapy.  Improved quality of life and better sleep resulted.  Nabilone treatment resulted in improved physical ability including the ability to bear weight, resume work, and perform housework.  There were few side effects, and patients did not develop tolerance to Nabilone.

Prior to Nabilone treatment, and despite receiving many different pain medications, these 10 CRPS patients suffered burning painallodynia, autonomic nervous system changes, and physical disability.  Pre-Nabilone, all 10 CRPS patients ranked CRPS pain as 10 out of 10 (on 10-point visual analog scale; VAS).

Importantly, post-Nabilone therapy, overall pain decreased to 3 – 6 (on VAS) in all 10 CRPS patients.

Fibromyalgia patients reported that Nabilone offered significant benefits in pain relief and functional improvement.

A cancer pain study reported that pain scores in Nabilone-treated cancer patients were significantly reduced, compared to those who were not treated with Nabilone.  Other improvements in Nabilone-treated cancer patients included reduced nausea, less anxiety/overall distress, and slight improvement in appetite.  Nabilone-treated cancer patients were also able to reduce (or discontinue) dosages of other drugs including nonsteroidal anti-inflammatory agents, tricyclic antidepressants, and gabapentin.

A cannabis extract may be used to treat refractory spasticity in multiple sclerosis.

POSSIBLE MECHANISMS

Cannabinoid agonists (including Nabilone) activate cannabinoid receptor types CB1 and CB2.  Activation of CB2 leads to anti-inflammatory effects including reduction of TNF-alpha-induced endothelial cell activation, monocyte migration and adhesion.  This may partly explain why cannabis and cannabinoids are able to reduce pain including nerve pain (CRPS, multiple sclerosis).

Wishing less pain to all pain patients,

Sabina Walker

References:

(1) Mark A. Ware; Cannabinoids in Pain Management: An Update from the 2009 Canadian Pain Society Meeting, Quebec QC

http://www.ccic.net/picture/upload/File/Viewpoints/Viewpoints_in_Cannabinoids_MASTER.pdf

(2) Berlach, Shir, Ware. Experience with the synthetic cannabinoid nabilone in chronic noncancer painPain Med. 2006 Jan-Feb;7(1):25-9.

http://www.rsds.org/pdfsall/Experience%20with%20the%20synthethic%20cannabinoid%20nabilone.pdf

(3) David Wild; Refractory CRPS Patients Discontinue Opiates With Cannabinoid Treatment (A Study by May Ong-Lam, MD, Clinical Assistant Professor, Dept of Medicine, St Paul’s Hospital, Vancouver); Pharmacy Practice News (8 Feb, 2011).

http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=239&i=January+2011&i_id=694&a_id=16601

(4) Skrabek RQ, Galimova L, Ethans K, Perry D; Nabilone for the treatment of pain in fibromyalgia. J Pain 2008;9(2):164-173.

http://www.ncbi.nlm.nih.gov/pubmed/17974490

(5) Maida et al, 2008. Adjunctive nabilone in cancer pain and symptom management: a prospective observational study using propensity scoring. J Support Oncol. 2008 Mar;6(3):119-24.

http://www.ncbi.nlm.nih.gov/pubmed/18402303

(6) Grotenhermen, Müller-Vahl; The therapeutic potential of cannabis and cannabinoidsDtsch Arztebl Int (2012 July);109(29-30):495-501.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442177/

(7) Rajesh et alCB2-receptor stimulation attenuates TNF-alpha-inducedCB2-receptor stimulation attenuates TNF-alpha-induced human endothelial cell activation, transendothelial migration of monocytes, and monocyte-endothelial adhesion; Am J Physiol Heart Circ Physiol (2007 Oct);293(4):H2210-8.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2229632/