Anaesthetics And The Treatment Of Neuropathy

Today's post from asahq.org (see link below) is a general assessment of neuropathy treatment at the moment, from the American Society of Anaesthesiologists and looks particularly at anaesthetics as pain killers, including such drugs as ketamine. The problem is that there are no definite conclusions here. Ketamine is seen as a promising analgesic agent for neuropathy sufferers but there's little discussion of opioids in general and no mention of methadone for instance, which is proving very successful in nerve pain cases. Nevertheless, this does look at neuropathy treatment from the point of view of anaesthesiologists and as such gives us another angle on the subject.

Causes of Neuropathic Pain Guide Treatments
Timothy Lubenow, M.D., Philip Peng, M.B.B.S., and Jianguo Cheng, M.D., Ph.D. 2014

Neuropathic pain is one of the most complex and difficult management challenges physician anesthesiologists face. Hundreds of distinct neuropathic pain syndromes have been documented and many are refractory to multiple treatments.

“Neuropathic pain affects 18 percent of the general U.S. population,” said Jianguo Cheng, M.D., Ph.D., Professor and Director of the Pain Medicine Fellowship Program at the Cleveland Clinic in Cleveland. “It is a major part of our practice and very resource-intensive. Medical costs for neuropathic pain patients are threefold higher compared with matched control subjects.”

Neuropathic pain is caused by a lesion or insult in the peripheral or central nervous system. The resulting plasticity in the peripheral and central nervous system leads to sensitization and hyperexcitability of neurons in the dorsal root ganglion, the spinal cord and the brain. The result is hyperalgesia, allodynia and spontaneous pain.

Causes include post-surgical, post-traumatic or post-herpetic neuralgia, diabetic neuropathy, HIV neuropathy, hypothyroidism, toxic exposures, lesions of the central nervous system, complex regional pain syndromes and more.

“Treatment of neuropathic pain has two goals,” said Timothy Lubenow, M.D., Professor of Anesthesiology, Rush University Medical Center, Chicago. “We want to alleviate or eliminate the cause of the underlying disease and to relieve symptoms.”

Treating the underlying cause is vital to long-term control, he said. For example, it is virtually impossible to successfully treat diabetic neuropathy until the underlying diabetes is brought under control.

Step therapy is standard for treating neuropathic pain, Dr. Lubenow said. Most patients can be treated with drug therapy, typically combinations of agents with different mechanisms of action. Multiple medical societies have issued guidelines for neuropathic pain, most with somewhat different recommendations. There are a wealth of anecdotal reports and open-label studies, and a dearth of strong evidence.

“When the evidence is soft, it is more open to interpretation and opinion,” he said. “You want a drug or a combination of drugs that are useful in alleviating pain, but you also want to minimize side effects.”

Pregabalin, gabapentin and duloxetine appear as preferred agents in most guidelines, Dr. Lubenow said. Other agents frequently recommended include sodium valproate, oxycarbazepine, venlafaxine, amitriptyline, dextromethorphan tramadol, morphine, oxycodone and capsaicin.

For patients with recalcitrant pain, spinal cord stimulation and intravenous infusion may be viable alternatives.

There are data supporting the use of I.V. lidocaine, bisphosphonates, phentolamine and immunoglobulin, said Philip Peng, M.B.B.S., Professor of Anesthesiology and Pain Management at Toronto Western Hospital, University of Toronto. But the duration of analgesia tends to be short, and severe adverse events are common.

Ketamine is one of the most promising I.V. agents for neuropathic pain, he said. Most studies use 50 mg or less infused over 30 minutes to two hours and the analgesic effect lasts less than two days. Trials using larger doses over longer infusion periods show much greater effect.

A study using anesthetic doses infused over five days showed significant pain relief up to six months following treatment, but there were significant psychotropic effects, muscle weakness and infections. Later trials using lower doses showed less severe adverse events but also less analgesia.

Early data from a Toronto Western Hospital trial using six-hour outpatient infusions for five days showed slightly more non-responders than responders, Dr. Peng reported. But responders showed greater than 50 percent pain relief up to three months after treatment.

“Responders tend to have less pain by the end of the second day,” he said. “At this point, we have no good tool for predicting responders. We are hoping for more robust data as the protocol progresses.”

http://www.asahq.org/annual%20meeting/go%20anesthesiology%202015/asa%20daily%20news/causes%20of%20neuropathic%20pain%20guide%20treatments

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Just How Effective Are Opioids In Neuropathy Treatment

Today's post from medpagetoday.com (see link below) is an interesting review of a large-scale study of the effects of opioid treatment on people with neuropathy. It concludes that opioid use has its limitations but there is no evidence that it is either, over-prescribed by doctors, or abused by patients. This removes it immediately from the current hysteria concerning opioid medication and recognises that people with severe neuropathy have very few options. As a result, it calls for new medication development, not to remove the 'evils' of opioids but to provide a better alternative for patients in chronic pain. Definitely worth a read though maybe a little disheartening for people who rely on opioids to dampen their symptoms, having already exhausted all other options.

Long-Term Opioids May Not Help in Polyneuropathy
by Kristin Jenkins Contributing Writer, MedPage Today May 23, 2017 Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner last updated 05.23.2017
 
Action Points

Long-term opioid therapy among patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, according to a retrospective population-based study.
Note the data agree with prior studies showing opioid use disorders are more prevalent among those receiving long-term opioid therapy, but did not indicate that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.


Long-term opioid therapy in patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, researchers said.

Data from a retrospective, population-based cohort study showed that 18.8% of 2,892 patients with polyneuropathy received opioids continuously for at least 90 days compared to 5.4% of 14,435 controls. They were also more likely to rely on gait aids and have difficulty climbing stairs (adjusted HR 1.7) and experience depression (adjusted HR 1.53), opioid dependence (aHR 2.85), and opioid overdose (aHR 5.12) compared to controls, Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn, and colleagues reported online in JAMA Neurology.

"By showing that polyneuropathy increases the risk of long-term opioid therapy and that long-term opioid therapy is not associated with improved functional status but is associated with adverse outcomes, this study provides useful information to counsel patients with polyneuropathy who are considering or are already receiving opioid therapy," the researchers said. "Furthermore, it provides evidence that could influence treatment guidelines and health policy."

The researchers also reported that a diagnosis of opioid abuse among patients with polyneuropathy who were taking opioids for any length of time was observed in less than 2% of patients and that there was no significant association with overall mortality. However, there was a 7.2% rate of opioid dependence and a 2.6% rate of opioid overdose, they pointed out, adding that this "underscores that abuse and dependence are not synonymous."

"Thus, our results agree with those of prior studies citing that opioid use disorders are more prevalent among those receiving long-term opioid therapy, but we did not find that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.

Importantly, the study also showed that neurologists and pain physicians were only prescribing long-term opioid therapy in a small percentage of patients, a finding consistent with national trends, the researchers noted. "Therefore, it is likely that discussing potential benefits, as well as adverse outcomes, of long-term opioid therapy will fall to the primary care clinician," Klein and colleagues said.

For the study, the Rochester Epidemiology Project (REP) database was searched for prescriptions given to patients with polyneuropathy and for those given to controls in ambulatory practice. All data came from participants who resided in Olmsted County from Jan. 1, 2006, to Dec. 31, 2010 and were reported previously. The latest follow-up ended Nov. 25, 2016.

Patients with polyneuropathy receiving 90 days or more of opioid therapy were more likely to be female (57%) than those receiving short-term opioid therapy (P<0 .001="" 46="" 69="" age="" also="" although="" between="" br="" common="" commonly="" differences="" documented="" for="" groups="" in="" indication="" long-term="" median="" most="" musculoskeletal="" no="" of="" opioid="" oxycodone="" p="0.13)." pain="" patients="" polyneuropathy="" prescribed="" prescribing="" significant="" similar="" starting="" the="" therapy.="" there="" trends="" two="" versus="" were="" with="" xycontin="" years="">
Although rates of lower limb complications were comparable between the two groups, patients with polyneuropathy used non-opioid analgesics more often than controls.

In an accompanying editorial, Nora Volkow, MD, of the National Institute on Drug Abuse, and Walter Koroshetz, MD, of the National Institute of Neurologic Disorders and Stroke, noted that opioids in this study were prescribed more often for treatment of non-neuropathic indications. However, this finding doesn't change the evidence behind current guidelines advising against opioids as first-line treatment in most cases of neuropathic pain because of long-term safety concerns, they said.

The study also highlights the limited alternatives for managing chronic pain, and the urgent need to develop new medications, the editorialists said. Recent work in animal models demonstrate that innovative opioid peptides and biased opioid agonists may provide equivalent pain relief with less tolerance and fewer adverse effects while success with biologics for inhibiting pain at the its source may shift the focus to prevention, they said.

"In the meantime, structural changes in the healthcare system, including training of physicians in the screening and management of pain, as well as coverage by insurance of comprehensive pain management programs, are needed to ensure that patients receive the most effective treatments for their chronic pain conditions," Volkow and Koroshetz said.

Limitations of the study include the fact that it was based on prescription data without confirmation that prescriptions were filled or taken as intended.


This study was funded by the Mayo Foundation for Medical Education and Research, Mayo Clinic Center for Individualized Medicine, and the National Institutes of Health (NIH). The study authors disclosed no conflicts of interest. The editorialists disclosed no funding or conflicts of interest.

https://www.medpagetoday.com/neurology/painmanagement/65497

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Is Virtual Reality Hypnotherapy A Treatment Option For Neuropathic Pain

Today's post from tandfonline.com (see link below) is a fascinating subject and of possible value for neuropathy patients looking for potential future options regarding their own treatment. It concerns a case study of a patient who has already undergone multiple standard neuropathy treatments without success and contacted one of the authors with a view to trying Virtual Reality Hypnotherapy. Her fascinating story and experiences are shown below and open up the possibility of sophisticated hypnosis being a very useful and possibly standard tool in the treatment of nerve pain in the future. As always, it's assumed cost will be a determining factor.

Virtual Reality Hypnosis In The Treatment Of Chronic Neuropathic Pain: A Case Report 
Brent J. Oneal, David R. Patterson, Maryam Soltani, Aubriana Teeley, and Mark P. Jensen1,2 Volume 56, Issue 4, 2008

The publisher's final edited version of this article is available at Int J Clin Exp Hypn

See other articles in PMC that cite the published article.

Abstract

This case report evaluates virtual reality hypnosis (VRH) in treating chronic neuropathic pain in a patient with a 5-year history of failed treatments. The patient participated in a 6-month trial of VRH, and her pain ratings of intensity and unpleasantness dropped on average 36% and 33%, respectively, over the course of 33 sessions. In addition, she reported both no pain and a reduction of pain for an average of 3.86 and 12.21 hours, respectively, after treatment sessions throughout the course of the VRH treatment. These reductions and the duration of treatment effects following VRH treatment were superior to those following a trial of standard hypnosis (non-VR) treatment. However, the pain reductions with VRH did not persist over long periods of time. The findings support the potential of VRH treatment for helping individuals with refractory chronic pain conditions.

Hypnotic analgesia has become an increasingly important aspect in the treatment of clinical and experimental pain (Lang et al., 2000; Montgomery, DuHamel; Redd, 2000) and has been used on virtually every type of pain (Patterson; Jensen, 2003). Patterson and Jensen reviewed 29 randomized, controlled studies of hypnotic analgesia and concluded that (a) the evidence supporting the efficacy of hypnotic analgesia is strong, and (b) hypnotizability is usually related to outcome in studies that measure this variable. With respect to the importance of hypnotizability, one potential strategy for increasing the impact of hypnosis is to make hypnotic induction less effortful. We hypothesized that by providing visual stimuli for a patient during hypnosis treatment and giving the patient an illusion of “sinking into a virtual world,” the induction would require less concentration and mental effort from the patient and therefore might be more effective than standard hypnosis. As Patterson, Tininenko, Schmidt, and Sharar (2004) posited, using computer-generated stimuli to capture and to guide the patient's attention may not only make the induction less effortful but also more widely available, given that such a treatment would not require the presence of a clinician trained in hypnosis.

Although there have been few attempts to apply computer-generated hypnosis to clinical situations, results from a recent study on procedural pain revealed that hypnosis delivered through immersive virtual reality (VR) was very effective in reducing patients' reported pain and anxiety and may have reduced the need for opioid analgesics (Patterson, Wiechman, Jensen, Sharar, 2006). Immersive VR hypnosis (VRH) isolates patients from the outside world. With VR, patients have the illusion of going inside the three-dimensional computer-generated environment. Because VR is designed to be a highly attention-grabbing experience, it reduces the amount of attention available to process pain and instead maximizes the person's ability to narrowly focus on a hypnotic induction thereby facilitating dissociation of pain. The goal of creating VRH was to develop a three-dimensional, immersive virtual reality technology that could guide the patient through the same steps that are used when hypnosis is induced through an interpersonal process.

While there is a recent interest in using VR as a medium for hypnosis, this application is relatively new and has primarily been applied to acute procedural pain. The purpose of this case study was to expand the use of VRH to the treatment of a patient with chronic neuropathic pain, and, to our knowledge, it is the first research of its kind. In addition, in the present study, we were able to compare the results of the current trial of VRH to the results of a previous trial of standard hypnosis (non-VR) treatment that was conducted with the patient a few years earlier by one of the investigators. We hypothesized that this patient would have a significant reduction in pain and achieve a greater and longer lasting reduction in pain with VRH than standard (non-VR) hypnosis.

Case History

The patient was a 36-year-old female with a 5-year history of C4 tetraplegia and upper extremity neuropathic pain. She had no psychiatric history and was otherwise healthy. Approximately 5 years prior to the initiation of VRH treatment, she was injured as the passenger in a motor vehicle crash and spent close to 4 months in a major regional trauma center. Since that time, she has participated in both inpatient and outpatient rehabilitation and has worked closely with medical staff through a major regional multidisciplinary pain clinic. She described her pain as a constant burning sensation along the lateral aspects of her shoulders, medial arms, and proximal/anterior forearms, which was worse in her left arm. She was unable to wear clothes with sleeves as those garments increased her pain. She was also unable to be outdoors when there was any wind or precipitation due to her pain. In addition, her pain was very sensitive to temperature, and if the temperature was more than a few degrees above or below 73° F, her pain intensified. Finally, she also reported significant sleep difficulties secondary to her pain.

She has tried many treatments for pain management over the years, including multiple medications, physical therapy, massage therapy, acupuncture, Tibetan sound therapy, meditation, and electrical stimulation. Also, as noted above, she participated in a clinical trial of standard (non-VR) self-hypnosis training (Jensen et al., 2005, 2008). She reported that all of those treatments had been relatively unhelpful in the reduction of her pain.

Regarding past medications, this patient has tried over 15 medications to help her with pain management, including oxycodone, methadone, oxcarbazepine (Trileptal), venlafaxine (Effexor), diazepam (Valium), lorazepam (Ativan), pregabalin, mexiletine, and triazolam. She used to meet with her physician through the multidisciplinary pain clinic once every 3 weeks for pain management. However, for the year prior to the time that this study began, she had been meeting with that professional about once every 2 months.

During this study, the patient was taking the following medications: Diazepam 5 mg SID for sleep and pain; oxcarbazepine 300 mg SID for pain; trazodone 100–150 mg SID for sleep; mexiletine 150 mg BID for pain; venlafaxine 150 mg in am/75 mg in pm for pain; and tolterodine (Detrol LA) 4 mg SID for treatment of an overactive bladder.

Procedure

The patient became known to us after she contacted one of the authors with an interest in virtual reality distraction after hearing about this in the media. She was told that virtual reality distraction is not well suited for chronic pain but also that we could provide virtual reality hypnosis to see if this might be of benefit for her. The first two authors met with the patient to explain the study and VRH treatment. She consented to participate. The measures and data collection procedures for this study were very similar to those used in a previous trial of standard hypnosis (Jensen et al., 2005). Baseline and follow-up data was obtained from the patient by telephone interview. In order to determine the longer-term effects of having participated in VRH, the patient was asked to take a hiatus from treatment for a 1-month period. During that time one of the authors contacted her on a weekly basis by telephone to assess her comfort with the treatment hiatus and she was told that at any time during the break, if her pain became too intense, she was welcome to return to VRH sooner than the 1-month timeframe. Session logs were completed with the patient before and after each VRH session. The treatment outcome measures analyzed for this case report included average pain intensity and pain unpleasantness, as well as amount of time (in hours) the patient experienced a reduction or absence of pain between treatment sessions. The patient was also administered the Stanford Hypnotic Clinical Scale (SHCS; Morgan; Hilgard, 1978–1979) in order to assess level of hypnotizability.

The patient participated in a total of 33 VRH treatment sessions over the course of 6-months. All sessions occurred in a private office at a regional trauma medical center in Seattle, Washington. All sessions involved the patient receiving an audio recording of a hypnotic induction, suggestions for pain relief, and then alerting while drifting through a three-dimensional computer-generated virtual world called SnowWorld (See Patterson, Tininenko, Schmidt, Sharar, 2004; Patterson et al., 2006 for details of SnowWorld). Between sessions, the patient was encouraged to practice self-hypnosis regularly by using the compact disc that was given to her with the audio of the VRH protocol. In other words, she could listen to the audio version of the hypnosis at home, but did not have the visual stimuli available during the at-home practice sessions. She was also asked to complete daily diaries of her pain, unpleasantness, and frequency of home practice throughout the 6-months of treatment. She e-mailed the diaries to the first author of this article.

The VRH program began by having the patient hovering at the top of the snow canyon while an audiotape of the hypnotist's voice prepared the patient for what she would experience during the virtual hypnosis. After approximately 6 minutes of instruction, she began a 6-minute descent in the “snowy” 3-D canyon and she experienced herself as floating by numbers (1 through 10, in order) and was instructed to deepen her relaxation as she passed by each number. At number 10, she was told that she was in her most relaxed state and had descended deep into the canyon. At that point, she experienced herself hovering above the lake and was given about 18 minutes of audio posthypnotic suggestions. That was followed by approximately 10 minutes of alerting as she ascended back up the “snowy” 3-D canyon and floated by numbers (10 through 1, in order).

The Nature of Hypnotic Suggestions

Although the exact transcript of the hypnotic suggestions is too long to report, we will provide examples of the content. First, there was an introduction to the lake. The lake was described to the patient, and she was encouraged to become increasingly absorbed in the scene and to let her body relax. Then the program addressed her mind and how it could be a tremendous resource to help her feel safe and comfortable. The next section discussed how pain affects her life. An example of this dialogue is, “Part of you knows what it takes to feel more comfortable, to allow you to heal faster. It is there, it's just that it only comes to you, to your awareness, during certain times of your life, and what you realize is that this part of your mind is going to become present in your life during this time of healing, or during the time when you are undergoing pain.” The following segment dealt with asking the patient to imagine a time before the trauma. She was then instructed to recall images from a time in the past when she had positive experiences and to remember how comfortable she felt then.

After she was asked to recall positive images and experiences from her past, she was directed to move forward in time and to continue to see positive images of herself functioning well. She was told that images from the past and from the future should start to have a strong connection. Then the patient was given suggestions for sleeping better through the night, and it was also suggested that any exercises she engages in would become easier. It was recommended that she change the experience of her pain to a sense of coolness or numbness, or even forget about it altogether. She was also guided that as her pain improved she would find the ability to continue doing things that make her feel better, such as increasing her movement and participating more in life. The lake segment concluded by giving the patient a chance to engage in any other experiences or images that she might like to have, or to give herself positive suggestions of her own. She was then provided a period of silence for her to do that. The final suggestion focused on the fact that her comfort would be far greater when she took off the VR helmet than it was before she started the session.

Outcome Measures

The outcome measures analyzed for this study included pre- to posttreatment through 1-month follow-up of average pain intensity and pain unpleasantness. These outcome measures were the two that demonstrated significant effects in the original hypnosis only (non-VR) study that this patient previously participated in (Jensen et al., 2005). Both outcome domains were assessed at each outcome assessment point by contacting the patient four times within a 7-day window, and asking her to rate her usual pain intensity and pain unpleasantness over the past 24 hours on 0 (no pain; not bad at all) to 10 (the most intense pain sensation imaginable; the most intense bad feeling possible for me) Numerical Rating Scales. The four ratings for each outcome domain were then combined into composite measures of average pain intensity and pain unpleasantness.

In addition, the patient rated pain intensity and unpleasantness before and after each VRH session, using the same 0 to 10 Numerical Rating Scales described. These ratings were averaged into separate composite scores. That is, the pre- and postsession pain intensity and pain unpleasantness ratings were averaged for both the first 10 sessions and also all 33 sessions of VRH. Developing the composite scores from the first 10 sessions of VRH allowed for a direct comparison between VRH and the standard (non-VR) hypnosis trial, which included 10 sessions of treatment. The final outcome measure was the amount of time (in hours) that the patient experienced a reduction or absence of pain between treatment sessions. In the same manner as described above, these ratings were averaged into separate composite scores (VRH-33 sessions, VRH-first 10 sessions, standard hypnosis-10 sessions).

Outcome Data

Relative to the pretreatment baseline, the patient's ratings of average pain intensity and pain unpleasantness were not significantly different from her posttreatment or 1-month follow-up ratings. This outcome was similar for both the current VRH study as well as the hypnosis (non-VR) study that was conducted in 2004–2005. See Table 1 for the patient's average pain intensity and pain unpleasantness ratings pre/posttreatment as well as at 1-month follow-up for both the VRH and hypnosis (non-VR) treatments. In other words, VRH did not create lasting changes in the patient's pain perception.



Table 1


Means and SDs of Average Intensity of Pain and Pain Unpleasantness at Pretreatment, Posttreatment, and 1-Month Fallow-Up for VRH and Hypnosis Treatments

However, when investigating pain levels immediately after treatment, the patient's average pain intensity levels and pain unpleasantness ratings from pre- to posttreatment session, there was a 36% reduction in her average pain intensity and a 33% reduction in her average pain unpleasantness from pre- to post-VRH (see Table 2). As explained above, in order to directly compare the VRH and hypnosis (non-VR) ratings, the first 10 sessions of the VRH treatment were compared to the 10 sessions of hypnosis (non-VR) treatment that this patient had previously completed. See Table 2 for a depiction of the VRH 10-session and the hypnosis (non-VR) 10-session ratings. This patient reported an average of 25% pain intensity reduction and 20% pain unpleasantness reduction over the course of the first 10 sessions of VRH, compared to an average of 7% pain intensity reduction and 15% pain unpleasantness reduction over the course of the 10-session hypnosis (non-VR) treatment.



Table 2

Means and SDs of Presession to Postsession Intensity of Pain and Unpleasantness of Pain for 33-Sessions of Virtual Reality Hypnosis (VRH33), 10-Sessions of Virtual Reality Hypnosis (VRH10), and 10-Sessions of Hypnosis (Hyp10)

With respect to the duration of pain decrease between treatment sessions, this patient reported an average of 12.21 hours of pain reduction and 3.86 hours of being pain free over the course of the 33 sessions of VRH treatment. For the first 10 sessions of the VRH treatment she reported an average of 8.5 hours of pain reduction and 4.3 hours of being pain free, compared to an average of 1 hour of pain reduction and 0 hours of being pain free over the course of the 10-session hypnosis (non-VR) treatment (See Table 3).




Table 3

Means and SDs of the Duration (in Hours) of No Pain and Reduced Pain Throughout the Course of 33-Sessions of Virtual Reality Hypnosis (VRH33), 10-Sessions of Virtual Reality Hypnosis (VRH10), and 10-Sessions of Hypnosis (Hyp10)

Finally, on the Stanford Hypnotic Clinical Scale (Morgan; Hilgard, 1978–1979), the patient received a score of 2, placing her in the low to low-moderate range of hypnotizability.

Discussion
 
This report represents our first attempt to apply immersive virtual reality hypnosis to treat chronic neuropathic pain in a woman with a spinal cord injury who had not responded to any form of prior treatment. The patient's subjective ratings of pain intensity and pain unpleasantness showed an immediate reduction that averaged 36% and 33%, respectively, from pre- to post-VRH treatment. In addition, the amount of time that this patient experienced no pain or a reduction of pain over the course of the 33 VRH-treatment sessions averaged 3.86 and 12.21 hours, respectively. Furthermore, when compared to hypnosis alone (non-VR), this patient experienced a greater reduction in pain intensity and pain unpleasantness as well as longer lasting freedom from pain throughout the course of treatment with VRH.

The fact that this patient's pretreatment ratings of pain intensity and pain unpleasantness were not significantly different from her posttreatment and 1-month follow-up ratings of pain intensity and pain unpleasantness suggests that VRH treatment was helpful for her on a time-limited basis, that is, on average, 12.1 hours. The relatively short-lived effect of VRH in this patient's case is consistent with recent research suggesting that although hypnosis may not “cure” a person's chronic pain, it can be an important part of a person's plan to manage chronic pain on a daily basis (Jensen et al., 2008). In other words, hypnosis can provide many patients with a means of coping with pain, much like they might use medications (that also provide only short-term relief), but without the negative side-effects of those medications. In fact, research suggests that hypnosis can provide many beneficial “side effects” (e.g., improved well-being, improved sense of control over pain, improved sleep, etc.) that can contribute to a patient's quality of life over and above its effects on pain (Jensen et al., 2006).

Thus, even though some patients (about between 20%–30%, cf. Jensen et al., 2008) with chronic pain can experience substantial and long-term reductions in average daily pain following hypnosis treatment, many more patients than this report some relief of pain via hypnosis, view it as helpful and continue to use it up to 12 months following treatment. Therefore, although the patient in this case report was not “cured” of her pain, which would have been surprising given the refractory nature of it, she did achieve meaningful benefits through the use of VRH that lasted for many hours. Furthermore, while overall pain measurements did not change substantially, observation of means suggests that the directions of changes were in the direction anticipated. Specifically, overall ratings went down during the treatment period rather than baseline and then increased again during the month with no treatment.

The findings that this patient, who has suffered from severe and chronic neuropathic pain for over 5 years and has tried a myriad of other interventions, including over 15 medication trials, achieved a significant and lasting reduction in her pain throughout the course of VRH treatment is extremely promising. It was interesting that the patient went through the efforts to come to the hospital for months; given her spinal cord injury this was logistically difficult for her. It was also noteworthy that she reported that she benefited more from the induction when it was paired to the visual stimuli, rather than presented simply through audiotape. She also chose to resume treatment after a 1-month no-treatment period requested by the investigators. During one of the final VRH sessions before the treatment hiatus, this patient indicated that over time she was learning how to control her pain better, largely due to the experience that she has received through virtual reality hypnosis.

It was also noteworthy that the patient scored low on a scale measuring hypnotizability. Although the Stanford Hypnotic Clinical Scale is a screening measure, it has been reported to have good correlations with the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C; Bryant, Guthrie, Moulds, Nixon, and; Felmingham, 2003). The fact that the patient had a good response to the virtual reality hypnosis with a relatively low hypnotizability score is encouraging to us. Our hope is that this technology will be most useful to patients that do not have a high level of hypnotizability. Specifically, it may be that providing attention-grabbing stimuli that matches the suggestions may help patients become more absorbed in the process when this does not come naturally.

We maintain that this patient's chronic neuropathic pain is a challenging clinical problem with no easy solution. This report is provided after 6-months of treatment, with an empirical hiatus of no treatment. Our hope is that with repeated treatment, the pain relief experienced by the patient will last for greater, and hopefully more extensive, periods of time.

There are several limitations to this case report. As with a study of this design, we are not controlling for historical factors that might have influenced the patient's pain perception; randomized controlled studies are necessary to control such extraneous variables. One of the biggest threats to validity is not knowing if the patient reported pain reductions simply to please the investigators. However, we should note that she was willing to report no reductions in pain over several periods during the study. Further, although historical confounds are always a consideration, it is difficult to argue that the drops in pain that occurred over almost all of the 33 treatments were attributable to anything other than the intervention. The activity required to travel to the hospital was more likely to exacerbate than to reduce pain in itself. Finally, this technology used in the intervention was novel and has not yet been refined for use. In spite of these drawbacks, however, we view the pain reductions that occurred with VRH, especially in light of previous poor response to other treatments, as promising and indicate that additional investigation of virtual reality hypnosis for chronic pain is warranted.

Footnotes

1This article was supported by grants from the National Institutes of Health (R01 GM42725-09A1 and R01AR054115-01A1) as well as with gifts or grants from the Paul Allen Foundation, Scan Design by Inger and Jens Bruun Foundation, Gustavus and Louise Pffiefer Research Foundation, and other private donors. The software expertise necessary to design the immersive virtual reality delivery system was provided by Hunter Hoffman, Ph.D., at the University of Washington Human Interface Technology Lab as well as Ari Hollander at Imprintit.com.

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References

Bryant RA, Guthrie RM, Moulds ML, Nixon RDV, Felmingham K. Hypnotizability and posttraumatic stress disorder: A prospective study. International Journal of Clinical and Experimental Hypnosis. 2003;51:382–389. [PubMed]
Jensen MP, Barber J, Hanley MA, Engel JM, Romano JM, Cardenas DD, et al. Long-term outcome of hypnotic analgesia treatment for chronic pain in persons with disabilities. International Journal of Clinical and Experimental Hypnosis. 2008;56:157–170. [PubMed]
Jensen MP, Barber J, Hanley MA, Engel JM, Romano JM, Cardenas DD, et al. Hypnotic analgesia for chronic pain in persons with disabilities: A case series. International Journal of Clinical and Experimental Hypnosis. 2005;53:198–228. [PubMed]
Jensen MP, McArthur KD, Barber J, Hanley MA, Engel JM, Romano JM, et al. Satisfaction with, and the beneficial side effects of, hypnosis analgesia. International Journal of Clinical and Experimental Hypnosis. 2006;54:432–447. [PubMed]
Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, et al. Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomised trial. Lancet. 2000;355(9214):1486–1490. [PubMed]
Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and Experimental Hypnosis. 2000;48:138–153. [PubMed]
Morgan AH, Hilgard JR. The Stanford Hypnotic Clinical Scale for Adults. American Journal of Hypnosis. 1978–1979;21:134–147. [PubMed]
Patterson DR, Jensen M. Hypnosis and clinical pain. Psychological Bulletin. 2003;129:495–521. [PubMed]
Patterson DR, Tininenko JR, Schmidt AE, Sharar S. Virtual reality hypnosis: A case report. International Journal of Clinical and Experimental Hypnosis. 2004;52:27–38. [PubMed]
Patterson DR, Wiechman SA, Jensen M, Sharar SR. Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series. International Journal of Clinical and Experimental Hypnosis. 2006;54:130–142. [PubMed]

http://www.tandfonline.com/doi/abs/10.1080/00207140802255534?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed#.U5_rnbFqQUM

Treatment for sciatica pain in buttock

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Treatment Diagnosis of hernia

Diagnosis

For those who have an obvious hernia, the doctor might not require any other tests (if you're healthy otherwise). For those who have symptoms of a hernia (dull ache in groin or any other body area with lifting or straining but with no obvious lump), a doctor may feel the area while increasing abdominal pressure (having you stand or cough). This course of action may make the hernia capable of being felt. If you have an inguinal hernia, a doctor will feel for the possibility pathway and look for a hernia by inverting your skin of the scrotum together with his or her finger.

Treatment

Self-Care in your own home

In general, all hernias ought to be repaired unless severe preexisting health conditions make surgery unsafe. The potential exception to this is really a hernia with a large opening. Trusses and surgical belts or bindings might be helpful in holding back the protrusion of selected hernias when surgical treatment is not possible or should be delayed. However, they ought to never be used in the situation of femoral hernias.
Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that could cause the hernia to increase in dimensions

Medical Treatment

Treatment of a hernia depends upon whether it is reducible or irreducible and perhaps strangulated.
Reducible hernia
In general, all hernias ought to be repaired to avoid the potential of future intestinal strangulation.
For those who have preexisting medical conditions that will make surgery unsafe, your physician may not repair your hernia and can watch it closely.
Rarely, your physician may advise against surgery due to the special condition of the hernia.
Some hernias have or develop large openings in the abdominal wall, and shutting the opening is complicated due to their large size.
Most of these hernias may be treated without surgery, perhaps using abdominal binders.
Some doctors believe the hernias with large openings possess a low risk of strangulation.
Treating every hernia is individualized, along with a discussion of the risks and advantages of surgical versus nonsurgical management must take place between the doctor and patient.

Irreducible hernia

All acutely irreducible hernias need emergency treatment due to the risk of strangulation.
An attempt to lessen (push back) the hernia will normally be made, often after giving medicine for pain and muscle relaxation.
If unsuccessful, emergency surgical treatment is needed.
If successful, however, treatment depends upon the length of the time the hernia was irreducible.
If the intestinal items in the hernia had the circulation cut off, the development of dead (gangrenous) bowel can be done in as little as six hours.
In the event in which the hernia has been strangulated to have an extended time, surgical treatment is performed to check if the intestinal tissue has died and also to repair the hernia.
In the event in which the length of time the hernia was irreducible was short and gangrenous bowel isn't suspected, you may be discharged in the hospital.
Because a hernia which was irreducible and is reduced includes a dramatically increased chance of doing so again, you need to therefore have surgical correction at some point.

Occasionally, the long-term irreducible hernia isn't a surgical emergency. These hernias, having passed the exam of time without signs and symptoms of strangulation, may be repaired electively.

Treatment for a sciatic nerve in the leg

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Cancer Treatment And Peripheral Neuropathy Why

Today's post from mdanderson.org (see link below) looks at why cancer patients and patients undergoing cancer treatment, are susceptible to neuropathy. Most of you will have heard that cancer treatment is one of the more common causes of neuropathy, even if it's not the case with yourself but not many people know why this happens. This article doesn't go into impenetrable detail but does give a good general description of what's going on. Useful for cancer patients and their friends and family and also for everyone else living with neuropathy. Unfortunately none of us are immune to cancer and it can strike at any time. Worth a read.

Peripheral neuropathy in cancer patients
By Laura Nathan-Garner on June 18, 2014 

For many of our patients, peripheral neuropathy is among the unexpected side effects of cancer treatment.

It's caused by damage to your peripheral nerves -- that is, the nerves that are farther away from your brain and spinal cord. Certain complications of cancer or cancer treatments can cause or worsen neuropathy. So can some health conditions, such as diabetes, alcoholism, AIDS, hypothyroidism, rheumatoid arthritis and carpel tunnel syndrome.

We recently spoke with Julie Walker, advanced practice nurse in Neuro-Oncology, about peripheral neuropathy. Here's what she had to say.

What causes peripheral neuropathy in cancer patients?
The nerve damage that causes peripheral neuropathy may be the result of many different factors, including some chemotherapy drugs using vinca alkaloids, platinum compounds, taxanes and thalidomide.
Tumors themselves can cause nerve damage as well if they grow close to and press on the nerve.

And, patients with cancers of the nervous system -- such as brain tumors, spine tumors and skill base tumors -- are more likely to develop peripheral neuropathy due to nerve damage resulting from the tumor.

What are common peripheral neuropathy symptoms?
Symptoms depend on the type(s) and location(s) of the damaged nerves. The most common peripheral neuropathy symptoms include:

numbness
tingling
shooting pain or burning, especially in your fingers or toes. Other peripheral neuropathy symptoms include:

loss of balance, difficulty walking or frequent falls
clumsiness
difficulty picking up objects or buttoning your clothes
facial pain
hearing loss
loss of sensitivity to hot and cold
stomach pain
constipation


What can cancer patients do to relieve peripheral neuropathy?
If the neuropathy is related to something you can control, try to control the cause.

If your neuropathy is chemo-related, your oncologist can decide whether it's beneficial to reduce your chemotherapy dosage or switch to a different treatment regimen.

If it's related to diabetes, you can often slow down or stop the progression of peripheral neuropathy with better blood sugar control.

Beyond that, physical activity can help by keeping blood flowing in the affected areas. Some people also try acupuncture.

Over-the-counter pain relievers and prescription medications like carbamazepine and Lyrica may help in some cases. Non-prescription-type treatments -- such as acetyl l-carnitine, alpha lipoic acid, glutamin, calcium and magnesium -- may help, too. But more research is needed to better gauge their effectiveness. Be sure to speak with your health care provider before trying any of these.

What can cancer patients do to lower their chances of developing peripheral neuropathy?
If you have other health conditions, such as diabetes, that can make the neuropathy worse, manage them appropriately. Limit alcohol use. Maintain a well-balanced diet. And, discuss your neuropathy risks with your health care provider.

How long do peripheral neuropathy symptoms last?
Every case is different. Because neuropathy is caused by nerve damage, it depends largely on how well your nerves recover. And, that depends on the length of your treatment, extent of the damage and, in the case of chemotherapy-induced neuropathy, dosage intensity.

It's usually possible to manage peripheral neuropathy up to a certain point, but for many people, it never goes away.

As the nerves heal, some people may actually experience more tingling in the affected area. Speak with your health care provider to find out if a prescription might help relieve symptoms during this time.

People with peripheral neuropathy lose the ability to feel pain or extreme temperatures in the affected areas.

What can cancer patients with peripheral neuropathy do to avoid burning or injuring themselves?
Always wear shoes to protect your feet from an injury. Also, make sure you examine your feet every day to look for any wounds or sores that aren't healing.

Be careful when using sharp utensils or avoid them altogether. Likewise, since neuropathy typically inhibits your fine motor movements, be cautious around or avoid dangerous machinery.

Before touching water with your hands or feet, feel the water with a part of your body -- such as the underside of your forearm -- that can sense how warm it is. And, avoid using heating pads and hot water bottles.

Any other advice for cancer patients who are experiencing neuropathy?
People with neuropathy are more prone to falls because they struggle to feel the ground beneath them, especially in the dark or an enclosed space. So:

use a nightlight
keep clutter and throw rugs off the floor
use handrails when taking the stairs
put handrails in the shower
use skid-free shower and bath mats

Neuropathy also makes the body more prone to infection since circulation is decreased and wounds don't heal as well. So it's a good idea to keep your skin moist to prevent cracking and, in turn, infection.

The most important thing you can do, though, is to speak with your health care provider as soon as you start to experience neuropathy symptoms. Together, you can hopefully find ways to manage your symptoms.

http://www2.mdanderson.org/cancerwise/2014/06/peripheral-neuropathy-in-cancer-patients.html

Crash Test Dummies and Neuropathy Treatment

Today's post from thebody.com (see link below) discusses the way in which medications meant for other diseases are used to treat neuropathy symptoms, often to very little effect. It describes the accepted treatment path through various types of drugs, for standard neuropathy patients, and looks at their side effects too. It was written almost exactly a year ago and we now know that strenuous efforts are being made to find efficient treatments, specifically designed to handle the effects of nerve damage but in fact little has changed on the doctors' prescription pads. It will take some years for real change to reach the patients but in the meantime, patients should know what they are taking, what it was designed for and what the side effect risks are.

Guinea Pigs, Crash Test Dummies and HIV/Neuropathy Treatment

By Dave R. June 14, 2012

Internet links shown in these posts are designed to provide more detailed information if required.

It's hard to estimate the impact of the latest news to hit the neuropathy forums (what! we can't have trending stories too?) but anyone who has recently Googled the words HIV and Neuropathy has been confronted by dozens of links referring to the news that Lyrica (or pregabalin) is pretty much useless for treating HIV or diabetes-related neuropathic pain. It's not often that the internet neuropathy community (normally a mild-mannered, stoical, too-busy-dealing-with-symptoms folk) spreads a story so quickly across their websites, blogs, forums and chat rooms and when it happens, it's for a good reason!

More Information: Lyrica (Pregabalin) Fails For HIV-Related Neuropathy

Tracking the progress of neuropathy treatments is normally like peering through thick fog. You read about the latest potential wonder treatment; get excited and then it disappears into the mud of research and testing. At that point you know that it may be years before it hits the chemists' shelves and a sort of jaded acceptance sets in. So we stick by the tried and tested but rarely 100% effective, 'second-hand' medication, normally used to treat other diseases and try to live with the side effects and minimal relief they bring. It's nothing the seasoned person living with HIV isn't totally used to. It's also nothing less than disturbing, that a drug which has long been regarded as a mainstay of neuropathy treatment is suddenly declared to be ineffective.

Never mind the financial waste; people have clearly been swallowing potentially dangerous drugs, sometimes over a very long period and for nothing!

The manufacturers of Lyrica (pregabalin) are Pfizer and they released this information themselves, claiming that it applies to HIV- and diabetes-related neuropathy which is somewhat strange when you consider that HIV and diabetes are potential causes of neuropathy, not separate strains of the same disease. Does this mean that Lyrica (or pregabalin) works for any of the other ninety-odd sorts of neuropathy? I'm not a molecular chemist but I seriously doubt that. Neuropathy is basically nerve damage and it creates symptoms that are pretty much universal throughout its various forms. Lyrica (pregabalin) is intended to treat those symptoms and can't treat the cause or the damage itself, so to label it with just two disease associations just doesn't make sense. I'm willing to be proved wrong.

Lyrica was, is and may still be in the future, widely prescribed for neuropathy as a means of reducing the symptoms of pain, tingling, numbness and so on. It is meant to influence neurological transmissions and signals across a variety of systems in the body, thus theoretically, blocking pain signals. It is also widely used to treat epilepsy. The fact that even the manufacturer itself has acknowledged that its effectiveness is minimal for neuropathic pain; has only confirmed what many people have long suspected and the mounting anger is completely understandable. People may give Pfizer credit for actually owning up and releasing their own research findings but the company have been under fire both from patients and in the courts for years, mainly because Lyrica (pregabalin) can be a drug with potentially very unpleasant side effects.

It was always a sort of accidental wet finger in the wind drug choice for neuropathy anyway but it was by no means the only one. You perhaps can't blame Pfizer for taking the science at face value and using its own drug to make money. I'll give them the benefit of the doubt: their original motives must have been to improve the lot of the neuropathy patient. However, somewhere along the line, a board room decision must have been made to continue promoting it for this purpose, when there were serious doubts as to its efficacy. At least the latter ineffectiveness has now finally been admitted.

The problem is: Lyrica (pregabalin) is not the only drug with dubious credentials for treating HIV-related pain problems.

After your doctor has decided to issue medication to help control your neuropathy, you follow -- almost universally across the world -- a progressive series of drug treatments. The hope is that one will help your symptoms enough to stick with it but the idea is that you can move onto others if the problem gets worse. Sounds great doesn't it? Lots of options! The problem is that each recommended drug already has a life treating something else and has been applied to neuropathy almost as an afterthought. This information is available in full elsewhere on this blog.

More Information: How Neuropathy Is Currently Treated

So if normal, over-the-counter analgesics don't work (and they generally don't) you move onto anti-depressants and more specifically Tricyclic antidepressants, such as Amitriptyline, or Nortriptyline. They have many different brand names to confuse you even more. They are of course intended to treat depression and for neuropathy the doses are generally lower, although because of the symptoms, doctors have been known to assume that depression comes in the same package as neuropathy and they issue 'normal' doses. However, only about a third of patients respond positively to them and pain or discomfort relief can be minimal. The side effects however, range from psychiatric to allergic and can be intolerable for some people.

More Information: Tricylic Antidepressants for Neuropathy

If you get too little relief from Tricyclic antidepressants, you generally move onto anti-convulsants, which are normally used to treat epileptic conditions. These include Gabapentin (Neurontin), Lyrica (Pregabalin), and Carbamazepine. People generally begin with Gabapentin and move on if they don't respond. However, some of these not only clash with certain HIV medications but the side effects can also be quite alarming; ranging from sleepiness, blurred vision and dizziness to clinical depression. Your kidneys should also be regularly checked because these drugs are renally excreted.

More Information: Drug Treatment of Neuropathic Pain

If the symptoms of neuropathy become almost unbearable, the last port of call is generally the opioid family, including Tramadol, Oxycodone, Fentanyl, Methadone and certain other morphine variants. Patients are generally started on low doses but the body quite quickly becomes dependant and addiction can be a real problem if the dosages are not carefully monitored. The problem with opioids is that quite often, the more you take; the more you need. They will help control the pain but it still won't be 100% removed and the effects on the mind can be disturbing to say the least. I personally, have yet to meet a treatment for neuropathic pain that doesn't mess with my head but that's by no means a universal reaction.

More Information: Opioids -- How Much Do They Help With Chronic Neuropathic Pain?

Opioids can cause relatively mild side effects, such as drowsiness, light-headedness, nausea, and constipation. However, if not taken with care, overdoses can slow down breathing and cause death. Thanks to their addictive qualities, they may also be a problem for people with a history of substance use. There is some evidence however that new developments in opioid use and refinement may well be much better suited to neuropathy sufferers but again, it's a question of waiting.

More Information: Will a Better Attitude Towards Opioids Help Neuropathy Sufferers?

All of these drugs have worked to some extent for some people and as there are no alternatives at the moment, we have to work with what's available. The problems are that they all have side effects and they were all originally intended to treat something else.

I've skimmed over the neuropathy options here but much more information can be found by following the links. The point is that people living with HIV are bombarded by drugs as it is. When you add the drugs necessary to control nerve pain problems to the list, it is not surprising that many people become depressed and frustrated; they often suffer as much from the medication side effects as from the disease itself.

Furthermore, most people take what's issued to them completely on trust. They assume that their doctors will tell them all the possible side effects and the effects of long-term use. It is also assumed that any clashes with other medication will be spotted and dealt with before they're issued. The problem is, doctors are also human and it's perhaps unrealistic to think that they carry all possible drug interactions and potential side effects in their heads. You are given a leaflet inside the box, with all the drug company's own information and that's always the 'fall-back' if anything goes wrong ... you should have read it sir!

For people with HIV however, that's just not acceptable or even enough any more and I believe we have the right to demand good first-hand advice from our doctors and specialists and also objective advice on and in our pill boxes; not just what the drug company wants us to know and will cover their asses in a law court. That's why, it is so frustrating when a drug company like Pfizer is forced to come clean and admit that one of its money-makers is no better than a placebo for treating neuropathy and worse, never was!

When issued with a prescription for neuropathy (and HIV) the only sensible advice here is to discuss it to your doctors, even when they're trying to usher you out of the room to make way for the next patient. After that, go home and do your own research on the internet and if anything concerns you, talk to your doctors again. Get a second opinion if you're really worried. The home doctor may well have a different approach and level of knowledge than the HIV specialist, or the neurologist. Then when you feel that you're armed with enough information and have begun the treatment, listen to your body. The lists of potential drug side effects on the leaflets are enough to turn you into an instant hypochondriac, so that doesn't mean rushing off to the doctor at the first sign of a headache or nausea, or whatever you may have seen on the list of potential side effects but it does mean sensibly evaluating if something is really wrong and after a week or so, just doesn't feel right. A phone call, or visit to your doctor is not much trouble for him or her but it can save you a lot of anxiety.

What this latest revelation from Pfizer has taught us is that we can't necessarily take advice at face value. We may need to be more responsible for arming ourselves with the right information and making sensible decisions in collaboration with our doctors, instead of it being just a one-way process. People living with HIV and its family of secondary diseases have been guinea pigs and crash test dummies for too long. We've earned the right to receive the best medication and information about that treatment possible; after all we've also earned the drug companies bucket loads of cash along the way!

This and other posts are based on my opinions and impressions of living with both neuropathy and HIV. Although I do my best to ensure that facts are accurate and evidence-based, that is no substitute for discussing your own treatment with your HIV specialist or neurologist. All comments are welcome.

http://www.thebody.com/content/67521/guinea-pigs-crash-test-dummies-and-hivneuropathy-t.html