Risk of Chronic Pain Doubles for People From Lower Socioeconomic Backgrounds

By Pat Anson, PNN Editor

People from lower socioeconomic backgrounds are twice as likely to develop chronic pain after an acute injury, according to UK researchers who found that smoking, fear of movement, and poor social support also raise the risk of chronic musculoskeletal pain (CMP).

The study, published in PLOS One, adds to a growing body of evidence linking economic, social and emotional stress to some chronic pain conditions.   

Researchers at the University of Birmingham analyzed over a dozen systematic reviews of clinical studies involving nearly half a million people with CMP. Their goal was to see what biopsychosocial factors are associated with CMP and potentially make pain treatment more difficult.

“The mechanisms of CMP are different to acute pain in that pain exists despite there no longer being evidence of ongoing healing, but rather due to a sensitized nervous system that creates a continued or repeated experience of pain despite no evidence of actual or potential tissue damage,” wrote lead author Michael Dunn, from the School of Sport, Exercise and Rehabilitation Sciences at University of Birmingham

“This transition from acute to chronic MSK pain is associated with the presence of many biopsychosocial factors such as fear avoidance, low mood, and work satisfaction or strain. Despite this, healthcare services conventionally utilize approaches to treat CMP based on understandings of acute MSK pain, with focus often on identifying and treating perceived injured or irritated MSK structures.”

Dunn and his colleagues say many treatments for MSK pain, such as physical therapy and surgery, work no better than a placebo. That is because they only focus on the injured body part, and fail to account for psychological and social factors that contribute to acute pain becoming chronic.

“Put simply, current healthcare approaches do not address all the reasons people do not get better,” Dunn said in a news release. “Not only are current healthcare approaches inadequate, they may also be discriminatory, with current healthcare approaches that are orientated around the injured body part being geared towards those from higher socioeconomic backgrounds who are less likely to experience these psychological or social factors.”

In addition to socioeconomic factors, Dunn says stress and depression also raise the risk of developing CMP. He doubts that any single risk factor is the sole cause of chronic pain, but a combination of them make recovery from an acute injury more problematic.

Dunn’s findings mirror those of several U.S. studies that found social and economic factors were intertwined with the prevalence of chronic pain. In a 2021 study, for example, nearly 45% of people living below the federal poverty level reported having back pain. Another study found that people who did not complete high school were significantly more likely to have joint pain from arthritis.   

People with less education often have blue-collar jobs requiring manual labor that may contribute to musculoskeletal pain. They also tend to have lower incomes and less access to healthcare.

Princeton researchers Angus Deaton and Anne Case were the first to report on the role socioeconomic issues play in so-called “deaths of despair,” which linked financial and social stress to rising rates of pain, suicide, substance abuse, and death in middle-aged white Americans.

How Gut Bacteria Changes the Immune System

By Dr. Narveen Jandu  

The human immune system changes with age. Immune responses start to become less robust as people get older, which makes them more vulnerable to certain infections and diseases.

However, immune system aging looks different from person to person. Research has shown that changes to the composition and diversity of the microorganisms in the gut may explain these differences in immune system aging.

The gut microbiome — the population of microorganisms that lives in the gastrointestinal tract — helps the body maintain a stable internal environment when it is faced with external changes. This is known as homeostasis. The gut microbiome supports homeostasis in different ways, such as through helping to keep the immune system alert, and digesting dietary fibre into short-chain fatty acids to strengthen the intestinal wall.

The gut microbiome also helps us to regulate our inflammatory reactions. Inflammation helps the body fight microorganisms that cause disease, and helps repair damaged tissues. However, as the composition of our gut microbiome changes with age, a low level of inflammation can become constant throughout the body. This is called inflammaging.

When inflammaging develops in the gut, it leads to a decrease in immune responses, which puts people at a higher risk for infection and disease.

Let’s take a closer look at the gut microbiome and how it changes with age.

Diversity of Bacteria Decreases with Age

Our gastrointestinal tract can be compared to a densely populated city inhabited by a variety of different bacteria, fungi, archaea and viruses collectively called the gut microbiota. In fact, compared to other parts of the body, the gut microbiome has the largest number of bacteria. In a healthy gut microbiome, there are four dominant families (or phyla) of microorganisms, including Firmicutes, Bacteroidetes, Proteobacteria and Actinobacteria.

Firmicutes and Bacteroidetes make up around 80 to 90 per cent of the gut microbiota in the digestive tract. Firmicutes help with the production of short-chain fatty acids to support intestinal health and the secretion of mucus to improve intestinal wall defence. Bacteroidetes metabolize complex carbohydrates into vitamins and nutrients, and help promote glycogen storage to improve glucose metabolism.

The gut microbiome and immune system work closely together. The microorganisms in the gut send out signals that are detected by immune sensors. This allows the immune system to regulate the beneficial bacteria in the gut, helping maintain immune homeostasis. Through this interaction, the adaptive immune system also receives stimuli from harmful substances called antigens, which trigger an immune reaction.

However, as people age, the composition and balance of microorganisms in the gut changes. This gives rise to microbial dysbiosis, which means there is a reduction in the number of beneficial bacteria in the gut, alongside a higher number and pro-inflammatory organisms and bacteria that can cause disease. In addition to this, research has also shown that the general diversity of bacteria in our gut also decreases with age.

Over time, the shortage of beneficial bacteria such as Firmicutes in older adults starts to compromise the integrity of their intestinal barrier, causing it to become leaky. This is because the Firmicutes family plays a very important role in keeping the intestinal wall healthy and strong by producing a short-chain fatty acid called butyrate. Short-chain fatty acids such as butyrate help provide nutrients to strengthen the intestinal wall, inform immune responses and lower inflammation.

When intact, the intestinal barrier works to prevent harmful bacteria from passing through the intestinal wall, entering the circulatory system and reaching important organs. However, when there are not enough gut bacteria to produce the short-chain fatty acids that are needed for the intestinal wall to function, bacteria are able to enter the bloodstream. This contributes to the formation of intestinal inflammaging, which refers to a low level of inflammation that becomes steady throughout the body with age.

Inflammaging creates an environment that is prone to inflammation, which is caused and maintained by several factors. These can include microorganism imbalances in the intestines (microbial dysbiosis), psychological stress, physical inactivity, poor nutrition and chronic infections.

When the body is exposed to these factors on a regular basis, cellular senescence occurs. Cellular senescence is a state in which cell growth is permanently arrested, which means that cells are no longer able to self-renew. Eventually, this leads to a decrease in immune responses, which are important to prevent foreign substances and pathogens from entering the body.

How to Maintain a Healthy Balance of Bacteria

There is a common saying that claims “you are what you eat.” Indeed, nutrition and diet play an important role in regulating the number of different microorganisms that live in the gut. This means that diet may also play a key role in the immune function of older adults.

The Mediterranean diet, known for its lower intake of refined carbohydrates, saturated fats, dairy products and red meat, has been shown to have a positive effect on the balance of microorganisms in the gut and the strength of the intestinal barrier. The Mediterranean diet has also been linked to a lower risk of Type 2 diabetes in older adults, allowing these individuals to live a longer and healthier life.

The use of probiotics and prebiotics can also help fight age-related inflammation. Probiotics, such as Lactobacilli and Bifidobacteria, are live microorganisms that can be consumed to support overall health. More specifically, probiotics help improve the function of the intestinal barrier and regulate immune responses by modifying the composition of the gut microbiome. However, there is still some debate around whether the acidic conditions in the stomach allow probiotics to survive long enough to be able to move into the intestine.

It is clear that the immune system has an intricate relationship with the gut microbiome. A healthy and well-balanced gut microbiome will strengthen the intestinal barrier, which helps to reduce inflammation throughout the body and support the immune system.

To achieve this, it is important to maintain a healthy and well-balanced lifestyle as we grow older. This can include lower intake of dairy products and red meats, and harnessing the benefits of probiotics and prebiotics.

Narveen Jandu, PhD, is a faculty member with the School of Public Health Sciences at the University of Waterloo in Canada. As a biomedical researcher, Dr. Jandu’s research has focused on studying the cellular mechanisms and pathophysiological consequences of infectious diseases.

This article was co-authored by Flore Van Leemput. a student in health sciences at the University of Waterloo.

This article originally appeared in The Conversation and is republished with permission.

Epstein-Barr Virus Emerging As Possible Cause of Chronic Pain

By Dr. Forest Tennant, PNN Columnist 

When most people hear about the Epstein-Barr virus (EBV), they may recall its reputation as the rather harmless "kissing disease" known as mononucleosis.  To the surprise of many, this previously unheralded virus has recently emerged as a cause of some cancers and painful disorders.

It is now clear that EBV must be contained and suppressed in order to relieve the pain and suffering of many persons with chronic pain. This column is an introduction to the critical involvement of EBV with several chronic pain conditions.

The Epstein-Barr virus is named after Drs. Anthony Epstein and Yvonne Barr. In 1964, they discovered the virus after they found it in a cancer common in Africa called Burkitt’s Lymphoma.  Since that time, EBV has been found to cause other cancers including nasopharyngeal, gastric, Hodgkin’s lymphoma, and leukemia.  Some estimate that EBV causes about 200,000 cancers a year.

About three years after Epstein and Barr discovered EBV, it was found to be the cause of infectuous mononucleosis, which is known to trigger autoimmune complications.  Autoimmunity is simply defined as some element in the body that attacks, erodes, and destroys tissue. 

In 1968, this author reported that mononucleosis could cause glomerulonephritis, an autoimmune renal disease.  Over the ensuing decades, EBV has also been associated with other autoimmune disorders, including hepatitis, rheumatoid arthritis, fibromyalgia, systemic lupus, and Sjogren's syndrome.

EPSTEIN-BARR VIRUS

In 2018, a seminal study documented that EBV could cause a number of painful medical conditions by activating specific genes.  Dr. John Harley and colleagues at Cincinnati Children's Hospital Medical Center, with funding from the National Institutes of Health, found that a viral protein called Epstein-Barr nuclear analog 2 (EBNA 2) binds to the deoxyribonucleic acid (DNA) of genes that promote autoimmunity and some chronic pain conditions.

The pain conditions that Harley and his colleagues associated with EBV are multiple sclerosis, rheumatoid arthritis, celiac disease, type 1 diabetes, inflammatory bowel disease, thyroiditis, and juvenile arthritis.  Subsequent studies added Sjogren's syndrome, mixed connective tissue disease, and polymyositis to the list of EBV autoimmune conditions.

The Harley research is compelling.  We urgently need clinical studies of EBV in severe chronic pain patients to help develop new diagnostic, prevention, and treatment measures.  To this end, I've chosen to study the EBV relationship to painful spine and connective tissue diseases, especially adhesive arachnoiditis (AA) and Ehlers-Danlos syndrome (EDS). These conditions are considered intractable pain conditions in clinical pain practice. 

So far, we have collected EBV laboratory test results from over 80 persons with confirmed AA. Every case has demonstrated abnormally high levels of EBV IgG antibodies, which suggests the presence of autoimmunity and the possible invasion of brain and spinal tissue by the virus. 

Every patient with high IgG antibody levels also has herniated discs, and the majority have hypermobile EDS. Prior to developing AA, all had conditions associated with autoimmunity, such as fibromyalgia and small fiber neuropathy. All of them now have intractable pain.

How It Begins

Patients and clinicians concerned about chronic pain need to understand the basics of how EBV causes and aggravates chronic pain conditions. 

EBV is a member of the herpes virus family, which includes the other herpes viruses and cytomegalovirus.  It is a natural, lifelong parasite that usually infects children before the age of two. 

When EBV first enters the body, it is an “active” virus that may cause a cold, sinusitis, bronchitis, or possibly even go unnoticed. Infants and young children often have the “sniffles” and it could be mistaken as a simple cold. Some children who initially become infected with EBV later develop mononucleosis in their teenage or young adult life.  

After the initial infection, EBV settles into one’s lymphocytes and lining of the throat and nasal cavity to remain for life. Under normal physiologic circumstances, it is a latent or dormant parasite that does no harm.

Over 95% of adults will test positive for low levels of IgG antibodies, decades after their initial contact with EBV during childhood. When chronic pain patients are tested, autoimmunity is suspected if IgG antibodies are above normal levels found in the great majority of adults.

Once EBV has settled into lymphocytes or the throat lining and becomes dormant, it is living a harmless, symbiotic, parasitic life with its human host.  It will remain in this state, unless the body undergoes some kind of stress, usually trauma or an infection, that lowers or degrades the body's innate or natural immunologic protection systems. 

At this time, the virus may vacate its dormant or latent state to begin what is called a "lytic" or duplicative state.  The term used to indicate this state is "reactivation," meaning that the virus is again active, and attacking and invading new tissues. 

Once reactivated, EBV may create an autoimmune state by altering genes or by developing what is called an auto-antibody that will attack tissues.  In either case, an autoimmune state has been created that attacks normal tissues to produce inflammation, adhesions, scarring, and pain. 

Lymphocytes infected with reactivated EBV may enter any number of tissues. They may cross the blood brain barrier, enter the spinal cord and brain, and attack tissues such as the cauda equina, arachnoid membrane, intervertebral discs, and glial cells. This is the pathologic process in which EBV reactivation may cause chronic pain.

It is likely that entry and invasion of spinal canal and brain tissues may be responsible for the autoimmune manifestations seen after a stroke, head trauma, or complex regional pain syndrome (CRPS).  EBV may also be a cause of centralized pain that is associated with over-sensitization, hyperalgesia, and intractable pain.  There are reports that such common chronic pain conditions as fibromyalgia, small fiber neuropathy, and some arthropathies are caused by EBV autoimmunity.

This article's major intent is to inform all concerned parties that deal with chronic pain that EBV is not just some virus that causes the "kissing disease." It is a new revelation that compels an understanding and awareness that has the distinct potential to improve the plight of chronic pain patients. 

Laboratories and clinical researchers, including this author, are scurrying to identify more diagnostic, treatment, and preventive measures for EBV-caused autoimmunity. I'm pleased to report that our EBV project has been able to identify some initial testing and treatment measures which appear to be effective and a good start in dealing with EBV autoimmunity.  We will share our findings in future articles.

Forest Tennant, MD, DrPH, is retired from clinical practice but continues his research on the treatment of intractable pain and arachnoiditis. Readers interested in learning more about this research should visit the Tennant Foundation’s website, Arachnoiditis Hope. You can subscribe to its bulletins here.

The Tennant Foundation gives financial support to Pain News Network and sponsors PNN’s Patient Resources section.  

Can Naproxen Help You Live Longer?

By Pat Anson, PNN Editor

There may be a hidden benefit to the pain reliever naproxen. The non-steroidal anti-inflammatory drug (NSAID) is primarily used to treat arthritis, muscle aches and joint pain, but might also give a boost to your life expectancy, according to the results of a preliminary study.

An international research team analyzed 12-years of health records for over 500,000 people enrolled in the UK Biobank study to see if prescription drugs taken for at least 3 months were associated with higher or lower death rates. Over 400 medications were studied, with patients who were prescribed the drugs compared to control groups that didn’t take them.

“As expected, most drugs harbor a negative effect on lifespan, probably due to the underlying negative effect of the disease the drug is intended for. Importantly, a few drugs seem to have a beneficial effect on lifespan,” wrote lead author Alejandro Ocampo, PhD, a professor at the University of Lausanne and CEO of Epiterna, a Swiss company studying ways to slow the ageing process.        

Ocampo and his colleagues identified four medications associated with lower death rates:

• Naproxen   

• Atorvastatin (a statin)

• Estradiol (female hormone replacement)

• Sildenafil (Viagra)

Statins have long been known to reduce the risk of heart attack and stroke, while estradiol lowers the risk of osteoporosis and bone fractures in post-menopausal women. Sildenafil is well known for treating erectile dysfunction, but also improves cardiovascular health and may even protect against Alzheimer's disease. It’s easy to see how those drugs might increase life expectancy.

The inclusion of naproxen is a bit of a surprise. The active ingredient in Aleve and other over-the-counter pain relievers, naproxen raises the risk of a heart attack, stroke or internal bleeding when taken in high doses or used long-term. High doses of naproxen in 250mg and 500mg tablets are available by prescription, which is what people in the study were taking.

Even at those high doses, researchers found that naproxen was associated with a 10% lower death rate when compared to people who didn’t take the drug. The protective effect was strongest for men on naproxen, who had mortality rates that were 13% lower.

The findings are preliminary, have not been peer-reviewed, and don’t establish a cause-and-effect relationship. We don’t know why or how naproxen helps people live longer, only that it’s associated with a longer lifespan.  

Interestingly, the research team found that two other pain relievers – morphine and paracetamol (acetaminophen) – are associated with shorter lifespans. Again, this may have more to do with the underlying conditions the drugs were prescribed for, rather than the medications themselves.

Ocampo says more research and clinical studies are needed to get a better understanding of the long-term harms and benefits of medication.

“The benefit on lifespan observed for several drugs in this retrospective study could only be truly determined by performing randomized controlled trials. Such studies would aim at treating a healthy aging population with a drug during a sufficiently long follow-up to be able to observe the effect on all-cause mortality,” Ocampo wrote.

If the life expectancy benefits are proven, researchers say it could result in some drugs being “repurposed” as anti-aging treatments for otherwise healthy older adults.

Can Two Questions Identify ‘High Risk’ Pain Patients?

By Pat Anson, PNN Editor

“Have you ever felt your pain is terrible and it's never going to get any better?”

“Have you ever used an illegal drug or prescription medication for non-medical reasons?”

If you answered yes to both questions, you’d be considered at high risk of a “poor pain outcome” at Duke University’s Health System. You’d also be invited into a specialized pain management program that takes a more holistic approach to pain treatment.

Duke’s Integrated Pain and Wellness (IPW) Program was launched in 2019 to identify and treat pain patients at high risk of long-term opioid use, which can result in more frequent and costly visits to hospitals and emergency rooms. It’s one of several efforts in recent years aimed at identifying high risk patients, such as the controversial analytical software used by NarxCare or the far simpler Opioid Risk Tool survey.

Many pain patients feel stigmatized by these risk assessments, and feel they’ve been weaponized solely to deny them treatment with opioids.   

The IPW program is a little different. Patients are encouraged – but not required – to reduce their use of opioids, try non-opioid treatments, and undergo behavioral health therapies to help them learn how to accept their pain without being obsessed by it.     

“Our goal was to establish a comprehensive, integrated approach to pain management that prioritizes early intervention, reduces the dependency on opioids by providing alternative pain management strategies, and decreases the utilization of acute care resources,” wrote Padma Gulur, MD, a Professor in Anesthesiology and Population Health Sciences at Duke University School of Medicine. 

Gulur and her colleagues assessed how 432 patients at the highest risk of poor pain outcomes did after being enrolled in the IPW program.  

Their findings, published in NEJM Catalyst, show that about half the patients (224) reduced their opioid use within 30 days, while a small number (50) increased their opioid use. 

The average improvement in self-reported pain scores was modest (from 6.56 down to 6.11), as were minor improvements in physical function, anxiety, depression and fatigue.  

There were more robust signs of the IPW program’s success in reducing healthcare utilization, with emergency room visits falling by 26% and hospital admissions declining by 43% among the high-risk patients. 

“This approach led to marked patient improvements in both physical and psychological health outcomes,” Gulur said. "By demonstrating the effectiveness of early identification and intervention for patients at risk of poor pain outcomes, this research can inform the development of new therapies and treatment approaches focused on prevention.” 

One hurdle that remains is getting more patients to participate. Of the 13,561 patients who answered “yes” to both questions in the high-risk assessment, less than 11% accepted a referral into the IPW program. Researchers say many were already being treated at pain clinics outside Duke Health and declined to participate.

Toxic Stress Can Lead to Chronic Illness

By Dr. Lawson Wulsin  

COVID-19 taught most people that the line between tolerable and toxic stress – defined as persistent demands that lead to disease – varies widely. But some people will age faster and die younger from toxic stressors than others.

So how much stress is too much, and what can you do about it?

I’m a psychiatrist specializing in psychosomatic medicine, which is the study and treatment of people who have physical and mental illnesses. My research is focused on people who have psychological conditions and medical illnesses as well as those whose stress exacerbates their health issues.

I’ve spent my career studying mind-body questions and training physicians to treat mental illness in primary care settings. My forthcoming book is titled “Toxic Stress: How Stress is Killing Us and What We Can Do About It.”

A 2023 study of stress and aging over the life span – one of the first studies to confirm this piece of common wisdom – found that four measures of stress all speed up the pace of biological aging in midlife. It also found that persistent high stress ages people in a comparable way to the effects of smoking and low socioeconomic status, two well-established risk factors for accelerated aging.

Good Stress vs. Toxic Stress

Good stress – a demand or challenge you readily cope with – is good for your health. In fact, the rhythm of these daily challenges, including feeding yourself, cleaning up messes, communicating with one another and carrying out your job, helps to regulate your stress response system and keep you fit.

Toxic stress, on the other hand, wears down your stress response system in ways that have lasting effects, as psychiatrist and trauma expert Bessel van der Kolk explains in his bestselling book “The Body Keeps the Score.”

The earliest effects of toxic stress are often persistent symptoms such as headache, fatigue or abdominal pain that interfere with overall functioning. After months of initial symptoms, a full-blown illness with a life of its own – such as migraine headaches, asthma, diabetes or ulcerative colitis – may surface.

When we are healthy, our stress response systems are like an orchestra of organs that miraculously tune themselves and play in unison without our conscious effort – a process called self-regulation. But when we are sick, some parts of this orchestra struggle to regulate themselves, which causes a cascade of stress-related dysregulation that contributes to other conditions.

For instance, in the case of diabetes, the hormonal system struggles to regulate sugar. With obesity, the metabolic system has a difficult time regulating energy intake and consumption. With depression, the central nervous system develops an imbalance in its circuits and neurotransmitters that makes it difficult to regulate mood, thoughts and behaviors.

Though stress neuroscience in recent years has given researchers like me new ways to measure and understand stress, you may have noticed that in your doctor’s office, the management of stress isn’t typically part of your treatment plan.

Most doctors don’t assess the contribution of stress to a patient’s common chronic diseases such as diabetes, heart disease and obesity, partly because stress is complicated to measure and partly because it is difficult to treat. In general, doctors don’t treat what they can’t measure.

1 in 5 Americans Live with Toxic Stress

Stress neuroscience and epidemiology have also taught researchers recently that the chances of developing serious mental and physical illnesses in midlife rise dramatically when people are exposed to trauma or adverse events, especially during vulnerable periods such as childhood.

Over the past 40 years in the U.S., the alarming rise in rates of diabetes, obesity, depression, PTSD, suicide and addictions points to one contributing factor that these different illnesses share: toxic stress.

Toxic stress increases the risk for the onset, progression, complications or early death from these illnesses.

Because the definition of toxic stress varies from one person to another, it’s hard to know how many people struggle with it. One starting point is the fact that about 16% of adults report having been exposed to four or more adverse events in childhood. This is the threshold for higher risk for illnesses in adulthood.

Research dating back to before the COVID-19 pandemic also shows that about 19% of adults in the U.S. have four or more chronic illnesses. If you have even one chronic illness, you can imagine how stressful four must be.

And about 12% of the U.S. population lives in poverty, the epitome of a life in which demands exceed resources every day. For instance, if a person doesn’t know how they will get to work each day, or doesn’t have a way to fix a leaking water pipe or resolve a conflict with their partner, their stress response system can never rest. One or any combination of threats may keep them on high alert or shut them down in a way that prevents them from trying to cope at all.

Add to these overlapping groups all those who struggle with harassing relationships, homelessness, captivity, severe loneliness, living in high-crime neighborhoods or working in or around noise or air pollution. It seems conservative to estimate that about 20% of people in the U.S. live with the effects of toxic stress.

Recognizing and Managing Stress

The first step to managing stress is to recognize it and talk to your primary care clinician about it. The clinician may do an assessment involving a self-reported measure of stress.

The next step is treatment. Research shows that it is possible to retrain a dysregulated stress response system. This approach, called “lifestyle medicine,” focuses on improving health outcomes through changing high-risk health behaviors and adopting daily habits that help the stress response system self-regulate.

Adopting these lifestyle changes is not quick or easy, but it works.

The National Diabetes Prevention Program, the Ornish “UnDo” heart disease program and the U.S. Department of Veterans Affairs PTSD program, for example, all achieve a slowing or reversal of stress-related chronic conditions through weekly support groups and guided daily practice over six to nine months. These programs help teach people how to practice personal regimens of stress management, diet and exercise in ways that build and sustain their new habits.

There is now strong evidence that it is possible to treat toxic stress in ways that improve health outcomes for people with stress-related conditions. The next steps include finding ways to expand the recognition of toxic stress and, for those affected, to expand access to these new and effective approaches to treatment.

Lawson R. Wulsin, MD, is a Professor of Psychiatry and Family Medicine at University of Cincinnati. He also practices psychiatry in primary care settings, specializing in psychosomatic medicine.

This article originally appeared in The Conversation and is republished with permission.

Neurological Conditions Now Leading Cause of Chronic Illness

By Pat Anson, PNN Editor

The number of people living with neurological conditions such as migraine, diabetic neuropathy, epilepsy, stroke and dementia has risen significantly over the past 30 years, making it the leading cause of chronic illness worldwide, according to a new analysis published in The Lancet Neurology.

An international research team estimates that over 3.4 billion people – about 43% of the global population – had a neurological condition in 2021, replacing cardiovascular disease as the leading cause of poor health.

“The worldwide neurological burden is growing very fast and will put even more pressure on health systems in the coming decades,” said co-author Valery Feigin, MD, Director of the National Institute for Stroke and Applied Neuroscience at Auckland University in New Zealand.

“Yet many current strategies for reducing neurological conditions have low effectiveness or are not sufficiently deployed, as is the case with some of the fastest-growing but largely preventable conditions like diabetic neuropathy and neonatal disorders. For many other conditions, there is no cure, underscoring the importance of greater investment and research into novel interventions and potentially modifiable risk factors.”

A total of 37 disorders affecting the brain and nervous system were included in the study. Collectively, the nerve disorders are responsible for 443 million years of healthy life lost due to illness, disability or premature death, known as disability-adjusted life years (DALYs).

Tension-type headaches (about 2 billion cases) and migraines (about 1.1 billion) are the two most common neurological disorders, while diabetic neuropathy is the fastest-growing one. Painful stinging or burning sensations in the nerves of the hands and feet are often the first symptoms of diabetes.

“The number of people with diabetic neuropathy has more than tripled globally since 1990, rising to 206 million in 2021,” said co-senior author Liane Ong, PhD, from the Institute for Health Metrics and Evaluation at University of Washington. “This is in line with the increase in the global prevalence of diabetes.”

Over 80% of neurological deaths and disability occur in low- and middle-income countries, with western and central sub-Saharan Africa having the highest DALY rates. In contrast, high-income countries in the Asian Pacific and Australasia regions had the lowest rates.

“Nervous system health loss disproportionately impacts many of the poorest countries partly due to the higher prevalence of conditions affecting neonates and children under 5, especially birth-related complications and infections,” said co-author Tarun Dua, MD, Unit Head of WHO’s Brain Health unit.

“Improved infant survival has led to an increase in long-term disability, while limited access to treatment and rehabilitation services is contributing to the much higher proportion of deaths in these countries.”

Medical providers specializing in neurological care are unevenly distributed around the world, with wealthy countries having about 70 times the number of specialists as low-income ones.

Researchers say prevention needs to be a top priority in addressing the growth of neurological conditions. Some disorders, such as stroke and chronic headache, are potentially preventable by lowering risk factors such as high blood pressure, smoking and alcohol use.

The study was funded by the Bill and Melinda Gates Foundation.

Researchers Find No Clear Link Between Weather and Pain

By Pat Anson, PNN Editor

The Greek philosopher Hippocrates in 400 B.C was one of the first to suggest that changes in the weather can worsen pain conditions. Since then, a large body of folklore and personal anecdotes have reinforced that belief – although the science behind it is mixed, at best.

A large new systematic review – a study of studies – is once again throwing cold water on the common belief that chilly, rainy weather can trigger muscle and joint pain.

“There is a common perception that there is an increase of musculoskeletal symptoms such as back pain, hip pain or arthritic symptoms during certain types of weather,” said lead author Manuela Ferreira, PhD, Principal Research Fellow at the Institute of Bone and Joint Research, the University of Sydney. “Our research challenges that thinking by showing that come rain or shine, weather has no direct link with most of our aches and pains.”

Ferreira and her colleagues started out by reviewing over 1,100 studies involving weather and pain, rejecting most because they were small or poor quality. Only eleven studies met their criteria for inclusion. An analysis of those studies found no sign that humidity, air pressure, temperature or precipitation significantly raise the risk of a pain flare from rheumatoid arthritis or low back and knee pain.

But they did find evidence that a combination of warm temperatures and low humidity is associated with a higher risk of a pain flare in people with gout, a form of arthritis that causes severe pain and swelling in the joints of the feet and lower legs.

The study was published in the journal Seminars in Arthritis and Rheumatism.

“Although changes in weather conditions are frequently described by patients as triggers for pain and other symptom exacerbation, they do not appear to be significant risks for knee, hip, low back pain, or headache exacerbation, and have a small influence in symptom exacerbation of gout disease,” researchers concluded.

A 2017 study in Australia had similar findings, showing no association between back pain and changes in temperature, humidity, air pressure, wind direction or precipitation. Damp weather appeared to make people more aware of their pain, but the symptoms disappeared as soon as the sun came out – suggesting there’s a psychological cause.

Another recent study in the UK found only a modest association between weather and pain. The Cloudy with a Chance of Pain study collected data from 10,500 people who recorded their daily pain levels on a smartphone app for over a year. The GPS location of their phones was then compared to local weather conditions. Participants reported feeling more pain on days with low barometric pressure – and the wet and windy weather that usually comes with it.

Hippocrates may or may not have a point, but researchers say people in pain would be better off paying less attention to the weather and more on getting treatment.

“When seeking pain prevention and relief, both patients and clinicians should focus on how to best manage the condition, including weight management and exercises, and not focus on the weather and let it influence treatment,” says Ferreira.

U.S. Healthcare System Isn’t Ready for Surge of Disabled Seniors

By Judith Graham, KFF Health News

The number of older adults with disabilities — difficulty with walking, seeing, hearing, memory, cognition, or performing daily tasks such as bathing or using the bathroom — will soar in the decades ahead, as baby boomers enter their 70s, 80s, and 90s.

But the health care system isn’t ready to address their needs.

That became painfully obvious during the covid-19 pandemic, when older adults with disabilities had trouble getting treatments and hundreds of thousands died. Now, the Department of Health and Human Services and the National Institutes of Health are targeting some failures that led to those problems.

One initiative strengthens access to medical treatments, equipment, and web-based programs for people with disabilities. The other recognizes that people with disabilities, including older adults, are a separate population with special health concerns that need more research and attention.

Lisa Iezzoni, 69, a professor at Harvard Medical School who has lived with multiple sclerosis since her early 20s and is widely considered the godmother of research on disability, called the developments “an important attempt to make health care more equitable for people with disabilities.”

“For too long, medical providers have failed to address change in society, changes in technology, and changes in the kind of assistance that people need,” she said.

Among Iezzoni’s notable findings published in recent years:

Most doctors are biased: In survey results published in 2021, 82% of physicians admitted they believed people with significant disabilities have a worse quality of life than those without impairments. Only 57% said they welcomed disabled patients.

“It’s shocking that so many physicians say they don’t want to care for these patients,” said Eric Campbell, a co-author of the study and professor of medicine at the University of Colorado.

While the findings apply to disabled people of all ages, a larger proportion of older adults live with disabilities than younger age groups. About one-third of people 65 and older — nearly 19 million seniors — have a disability, according to the Institute on Disability at the University of New Hampshire.

Doctors don’t understand their responsibilities: In 2022, Iezzoni, Campbell, and colleagues reported that 36% of physicians had little to no knowledge of their responsibilities under the 1990 Americans With Disabilities Act, indicating a concerning lack of training. The ADA requires medical practices to provide equal access to people with disabilities and accommodate disability-related needs.

Among the practical consequences: Few clinics have height-adjustable tables or mechanical lifts that enable people who are frail or use wheelchairs to receive thorough medical examinations. Only a small number have scales to weigh patients in wheelchairs. And most diagnostic imaging equipment can’t be used by people with serious mobility limitations.

Iezzoni has experienced these issues directly. She relies on a wheelchair and can’t transfer to a fixed-height exam table. She told me she hasn’t been weighed in years.

Among the medical consequences: People with disabilities receive less preventive care and suffer from poorer health than other people, as well as more coexisting medical conditions. Physicians too often rely on incomplete information in making recommendations. There are more barriers to treatment and patients are less satisfied with the care they do get.

Discrimination in Healthcare

Egregiously, during the pandemic, when crisis standards of care were developed, people with disabilities and older adults were deemed low priorities. These standards were meant to ration care, when necessary, given shortages of respirators and other potentially lifesaving interventions.

There’s no starker example of the deleterious confluence of bias against seniors and people with disabilities. Unfortunately, older adults with disabilities routinely encounter these twinned types of discrimination when seeking medical care.

Such discrimination would be explicitly banned under a rule proposed by HHS in September. For the first time in 50 years, it would update Section 504 of the Rehabilitation Act of 1973, a landmark statute that helped establish civil rights for people with disabilities.

The new rule sets specific, enforceable standards for accessible equipment, including exam tables, scales, and diagnostic equipment. And it requires that electronic medical records, medical apps, and websites be made usable for people with various impairments and prohibits treatment policies based on stereotypes about people with disabilities, such as covid-era crisis standards of care.

“This will make a really big difference to disabled people of all ages, especially older adults,” said Alison Barkoff, who heads the HHS Administration for Community Living. She expects the rule to be finalized this year, with provisions related to medical equipment going into effect in 2026. Medical providers will bear extra costs associated with compliance.

Also in September, NIH designated people with disabilities as a population with health disparities that deserves further attention. This makes a new funding stream available and “should spur data collection that allows us to look with greater precision at the barriers and structural issues that have held people with disabilities back,” said Bonnielin Swenor, director of the Johns Hopkins University Disability Health Research Center.

One important barrier for older adults: Unlike younger adults with disabilities, many seniors with impairments don’t identify themselves as disabled.

“Before my mom died in October 2019, she became blind from macular degeneration and deaf from hereditary hearing loss. But she would never say she was disabled,” Iezzoni said.

Similarly, older adults who can’t walk after a stroke or because of severe osteoarthritis generally think of themselves as having a medical condition, not a disability.

Meanwhile, seniors haven’t been well integrated into the disability rights movement, which has been led by young and middle-aged adults. They typically don’t join disability-oriented communities that offer support from people with similar experiences. And they don’t ask for accommodations they might be entitled to under the ADA or the 1973 Rehabilitation Act.

Many seniors don’t even realize they have rights under these laws, Swenor said. “We need to think more inclusively about people with disabilities and ensure that older adults are fully included at this really important moment of change.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Patients With Irritable Bowel Syndrome Have High Rates of Fibromyalgia

By Pat Anson, PNN Editor

A large new study has found high rates of fibromyalgia in patients with irritable bowel syndrome (IBS), adding to a growing body of evidence linking gut bacteria to chronic pain disorders. IBS patients were also more likely to have chronic fatigue syndrome (CFS).

The study, recently published in the journal Biomedicines, looked at more than 1.2 million IBS patients hospitalized in the U.S. over a three-year period. They found that the prevalence rate of fibromyalgia in the IBS patients was 10.7 percent, about five times higher than the fibromyalgia rate (1.4%) in the general adult population.

Fibromyalgia is a poorly understood condition characterized by widespread body pain, headaches, fatigue, insomnia and mood disorders; while IBS causes abdominal pain, cramps, bloating, gas and diarrhea. Gut bacteria has been associated with both IBS and fibromyalgia, but the exact mechanism of action remains unclear.

“This is yet another example where ailments in the gut are linked to ailments elsewhere in the body and mind,” said senior author Yezaz Ghouri, MD, an assistant professor of clinical medicine and gastroenterology at the University of Missouri School of Medicine. “As we continue to learn more about how gut health effects health elsewhere it is important that clinicians look for and manage somatic comorbidities in IBS patients.”

Fibromyalgia and CFS are known as “somatic” disorders because patients who have them often experience anxiety and depression – a tendency perhaps explained about the lack of effective treatments for their physical symptoms.

“Because IBS patients have higher prevalence of somatic comorbidities such as fibromyalgia and chronic fatigue syndrome, identifying and treating these disorders can improve their quality of life,” said lead researcher Zahid Ijaz Tarar, MD, a fellow in the division of gastroenterology and hepatology at the University of Missouri School of Medicine.

“Earlier identification of comorbidities is valuable to inform treatment strategies, including consulting other specialties such as rheumatology and psychiatry to improve the overall health outcomes in IBS patients.”

In addition to fibromyalgia, the research team found that hospitalized IBS patients were also significantly more likely to be white and female.  Less than one percent (0.42%) had a CFS diagnosis – a small percentage to be sure, but still higher than CFS rates in the general population (0.06%).

The high rates of fibromyalgia and CFS in IBS patients has led to speculation that poor diets or antibiotics may cause an imbalance of “bad” bacteria in the gastrointestinal system, allowing toxins to leak into the bloodstream and cause other health problems.

A recent study found that Klebsiella aerogenes, a bacterium that causes white blood cells to produce excess amounts of histamine, can trigger a painful immune system response.

Another study found that women with fibromyalgia have strikingly different types and amounts of bacteria than those without fibromyalgia. Faecalibacterium prausnitzii, a “good” bacterium that is normally abundant in the human gut, was found to be depleted in fibromyalgia patients. Other bacteria associated with IBS, CFS and interstitial cystitis were found to be abundant in fibromyalgia patients, but not in the healthy control group.  

Fascia: An Overlooked Cause of Chronic Pain

By Dr. Adam Taylor, Lancaster University

We are constantly reminded about how exercise benefits our bone and muscle health or reduces fat. However, there is also a growing interest in one element of our anatomy that is often overlooked: our fascia.

Fascia is a thin casing of connective tissue, mainly made of collagen – a rope-like structure that provides strength and protection to many areas of the body. It surrounds and holds every organ, blood vessel, bone, nerve fibre and muscle in place. And scientists increasingly recognise its importance in muscle and bone health.

It is hard to see fascia in the body, but you can get a sense of what it looks like if you look at a steak. It is the thin white streaks on the surface or between layers of the meat.

Fascia provides general and special functions in the body, and is arranged in several ways. The closest to the surface is the superficial fascia, which is underneath the skin between layers of fat. Then we have the deep fascia that covers the muscles, bones and blood vessels.

The link between fascia, muscle and bone health and function is reinforced by recent studies that show the important role fascia has in helping the muscles work, by assisting the contraction of the muscle cells to generate force and affecting muscle stiffness.

Each muscle is wrapped in fascia. These layers are important as they enable muscles that sit next to, or on top of, each other to move freely without affecting each other’s functions.

Fascia also assists in the transition of force through the musculoskeletal system. An example of this is our ankle, where the achilles tendon transfers force into the plantar fascia. This sees forces moving vertically down through the achilles and then transferred horizontally into the bottom of the foot - the plantar fascia – when moving.

Similar force transition is seen from muscles in the chest running down through to groups of muscles in the forearm. There are similar fascia connective chains through other areas of the body.

When Fascia Gets Damaged

When fascia doesn’t function properly, such as after injury, the layers become less able to facilitate movement over each other or help transfer force. Injury to fascia takes a long time to repair, probably because it possesses similar cells to tendons (fibroblasts), and has a limited blood supply.

Recently, fascia, particularly the layers close to the surface, have been shown to have the second-highest number of nerves after the skin. The fascial linings of muscles have also been linked to pain from surgery to musculoskeletal injuries from sports, exercise and ageing. Up to 30% of people with musculoskeletal pain may have fascial involvement or fascia may be the cause.

A type of massage called fascial manipulation, developed by Italian physiotherapist Luigi Stecco in the 1980s, has been shown to improve the pain from patellar tendinopathy (pain in the tendon below the kneecap), both in the short and long term.

Fascial manipulation has also shown positive results in treating chronic shoulder pain.

One of the growing trends for helping with musculoskeletal injuries is Kinesio tape, which is often used in professional sports, although evidence for its effectiveness is mixed. It is also being used to complement the function of the fascia, and is used to treat chronic lower back pain where fascial involvement is a factor.

Fascia in Disease

Aside from getting damaged, fascia can also provide paths that infections can travel along, within muscles.

The spaces between fascial layers are usually closed (think of cling film being folded over), but when an infection occurs, germs can spread between these layers. This is a particular problem in the neck, where there are several layers of fascia for infections to travel along. In severe cases, surgery is often needed to remove the dead tissue and save the healthy remaining tissue.

One of the primary examples of fascia functioning in health, and the challenges its dysfunction can bring, is seen in the common complaint plantar fasciitis, which causes pain on around the heel and arch of the foot.

This incredibly common ailment affects 5-7% of people, rising to 22% in athletes. It is recognised as an overuse injury, causing the thickening of the fascial bands on the soles of the feet that help give the arch support.

Fascia can also be implicated in more serious health conditions, such as necrotising fasciitis. This is a rare but serious bacterial condition that can spread through the body quickly and cause death.

The condition is almost always caused by bacteria, specifically group A Streptococcus or Staphylococcus aureus. The initial infection comes from a cut or scratch, and then the bacteria travel along the fascia to other areas away from the initial site of access and multiply in the ideal environment afforded by the warm recesses of the body.

One reason fascia has been overlooked in health and disease is because it was difficult to see using current imaging technology. More recently, though, MRI and ultrasound imaging have been shown to be beneficial in visualising fascia, particularly in musculoskeletal conditions such as plantar fasciitis, and pathological changes in the fascia of the shoulder and neck.

With the growing interest in fascia and the growing understanding of its contribution to musculoskeletal health, it’s sensible to suggest that we look after it in the same way we do with the rest of the musculoskeletal system - by using it. Simple techniques like foam rollers and stretching are beneficial in increasing mobility, but there is still much to learn about our fascia and the role it plays in our day-to-day health.

Adam Taylor, PhD, is a Professor and Director of the Clinical Anatomy Learning Centre at Lancaster University. His research interests lie within the field of osteoarthritis and the degeneration of cartilage and bone.

This article originally appeared in The Conversation and is republished with permission.

Childhood Trauma Raises Risk of Chronic Pain in Adults by 45%

By Pat Anson, PNN Editor

People who experienced neglect or physical, sexual or emotional abuse as children are significantly more likely to have chronic pain as adults, according to a large new analysis. Individuals who had adverse childhood experiences (ACEs) were 45% more likely to report chronic pain in adulthood than those who did not have childhood trauma.

“These results are extremely concerning, particularly as over 1 billion children – half of the global child population – are exposed to ACEs each year, putting them at increased risk of chronic pain and disability later in life,” says lead author André Bussières, PhD, an Assistant Professor at the School of Physical & Occupational Therapy at McGill University. 
 
“There is an urgent need to develop targeted interventions and support systems to break the cycle of adversity and improve long-term health outcomes for those individuals who have been exposed to childhood trauma.”  

Bussières and his colleagues reviewed 75 years of research involving over 826,000 people. Their findings, published in the peer-reviewed journal European Journal of Psychotraumatology, adds to the growing body of evidence showing an association between ACEs and chronic pain.

ACEs may affect a child directly through physical, sexual or emotional abuse, or neglect – or indirectly through exposure to environmental factors like domestic violence, living with substance abuse, or parental loss.

Physical abuse during childhood had the strongest association with chronic pain and pain-related disability. The odds of having chronic pain were also higher if a person experienced multiple ACEs, either alone or combination with indirect ACEs. The research does not prove that ACEs cause chronic pain, only that there’s an association.

“Our findings suggest ACE exposure is associated with the most common and costly chronic pain conditions, including back and neck pain and other MSDs (musculoskeletal disorders), which account for the highest total health care spending compared to other health conditions,” researchers said.

“People with ACEs tend to have a higher chronic disease burden, barriers to treatment engagement, and greater health care utilization in adulthood. Adult patients exposed to ACEs may not be achieving optimal health outcomes due to the physiological and psychological effects of toxic stress. While the relative contributions of these mechanisms are not yet well understood, emerging evidence links ACEs to changes in genetic expressions that affect structural and functional changes in the brain and clinical phenomena in adulthood.”

Still unclear is the role that ACEs play in specific pain-related conditions. Previous studies have linked childhood trauma to an increased risk of headache disorders, fibromyalgia and lupus, as well as mood and sleep problems.

Most Americans and Canadians Use OTC Drugs and Self-Care for Pain Relief

By Pat Anson, PNN Editor

Most Americans and Canadians who experience pain prefer over-the-counter drugs, exercise and bed rest over prescription pain medication, according to a large new survey. A surprising number of respondents said they do nothing or simply accept their pain.  

The online survey, led by a research team at Ontario’s Western University, asked over 4,100 adults in 2020 what types of treatment, medication or self-care methods they use to deal with or prevent pain. Respondents were given ten different pain management techniques to choose from.

The survey findings, published in the journal Innovation in Aging, show that most people use a combination of methods for pain relief, along with a healthy dose of stoicism. Over half said they use OTC pain relievers, often in combination with self-care techniques such as exercise, bed rest or physical therapy.

Over 41% selected “just live with pain” and 10% chose “do nothing” – which essentially amounts to pain acceptance.

Only one in four (24%) said they use prescription pain medication. Not surprisingly, respondents who said they had high pain levels were over four times as likely to use a prescription drug  

SOURCE: INNOVATION IN AGING

The responses from Americans and Canadians were similar, with one notable exception. Americans were twice as likely than Canadians to turn to alcohol to dull their pain, with just under 4% of Canadians using alcohol as a pain management strategy, compared to almost 8% in the U.S. Alcohol use jumped to 21% for those with the highest levels of pain in both countries.

"Our research shows that using alcohol to treat pain is somewhat common, unfortunately. Previous research has shown that is not only ineffective at treating pain, but it can actually be counterproductive," said lead author Anna Zajacova, PhD, a demographer and sociology professor at Western University. "Our study also indicates that there is likely a lot of unmet need for better treatment options for people to manage their pain."

Zajacova and her colleagues noted that high alcohol use in the U.S. may be a reflection of more limited access to healthcare than in Canada, which has a national health system.

"What we learned from this survey is that people aren't necessarily just visiting their doctor to manage their pain, and it's important to understand the non-medical and non-pharmacological strategies that people are using, for better or for worse," said Zajacova.

A major weakness of the study, which the authors acknowledge, is that they did not differentiate between acute, short-term pain and chronic pain. They also didn’t ask if the prescription pain medication used was an opioid or non-opioid.

WHO Releases First Guideline for Chronic Low Back Pain

By Pat Anson, PNN Editor

The World Health Organization (WHO) has released its first-ever guideline for managing chronic low back pain, recommending treatments such as exercise, physical therapy, chiropractic care and non-steroidal anti-inflammatory drugs (NSAIDs).

Chronic low back pain — also known as “non-specific low back pain” — is defined as pain that persists longer than three months, with symptoms that cannot be accounted for by a structural spinal problem or disease process such as arthritis.

Although lower back pain (LBP) is the leading cause of disability worldwide – affecting about 619 million people – there has been little certainty about how to treat it. Almost all of the clinical trial evidence reviewed by WHO’s guideline development group was considered low or very low quality, a persistent problem.in many medical guidelines dealing with pain.

The lengthy 274-page guideline takes a dim view of some commonly used therapies for LBP, such as muscle relaxants, anticonvulsants, steroids, opioids, transcutaneous electrical nerve stimulation (TENS), and injectable anesthetics – treatments that are primarily used in high-income countries. WHO recommends a more holistic approach to LBP, using therapies that are affordable and accessible to more people.

"Addressing chronic low back pain requires an integrated, person-centred approach. This means considering each person's unique situation and the factors that might influence their pain experience," Dr. Anshu Banerjee, WHO Director for Maternal, Newborn, Child, Adolescent Health and Ageing, said in a press release. "We are using this guideline as a tool to support a holistic approach to chronic low back pain care and to improve the quality, safety and availability of care."

WHO recommends that adults with chronic LBP start with treatments that are the least invasive and least potentially harmful. The values and preferences of patients should also be considered, as they are more likely to adhere to therapies they consider helpful.  

Recommended Treatments for Chronic LBP

• Patient education and counseling

• Exercise or physical therapy

• Acupuncture or dry needling

• Spinal manipulation (chiropractic care)

• Massage

• Cognitive behavioral therapy or mindfulness

• NSAIDs

• Topical cayenne pepper

The guideline states that opioid analgesics “should never be used as a stand-alone treatment” for chronic LBP. When opioids are used alongside other therapies, the lowest dose should be prescribed and only for a short duration, according to WHO.

Recommendations against routine use are also made about many other pharmaceuticals, including antidepressants, anticonvulsants, muscle relaxers, glucocorticoids (steroids), weight loss drugs, and injectable anesthetics such as lidocaine or bupivacaine.  

No recommendations are made about benzodiazepines, cannabis or acetaminophen (paracetamol), primarily due to lack of evidence, but also because of potentially harmful side effects. Cayenne pepper is the only herbal remedy recommended by WHO.

The guideline does not address surgical procedures such as spinal fusions and spinal cord stimulators, or invasive procedures such as epidural injections.

WHO’s 25-member guideline development group included a broad range of clinical experts from around the world. Among them is Roger Chou, MD, a researcher and longtime critic of opioid prescribing who heads the Pacific Northwest Evidence-based Practice Center. Chou is a co-author of the 2016 and 2022 CDC opioid guidelines, and has collaborated on several occasions with members of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid advocacy group. Chou let his Oregon medical license lapse in 2022.

One of the clinical trials reviewed by WHO’s guideline group is a controversial Australian study – known as the OPAL study -- that found low dose opioids gave little relief to patients with short-term back and neck pain. The OPAL study has been panned by critics because the treatment period only lasted six weeks and used a formulation of oxycodone that would not normally be used in clinical practice. Nevertheless, it’s been cited as evidence that “prolonged opioid use” is ineffective.

In 2021, WHO updated its guideline on the treatment of chronic pain in children, recommending that prescription opioids only be used for children who are dying or seriously ill. An earlier WHO guideline that recommended more pediatric use of opioids was withdrawn in 2019, after two U.S. congressmen accused the United Nation’s health agency of being “corruptly influenced” by opioid manufactures.  

Neuroplasticity: How the Brain ‘Rewires’ Itself

By Hilary Diefenbach, University of Colorado School of Medicine

High-profile sports like football and soccer have brought greater attention in recent years to concussions – the mildest form of traumatic brain injury.

Yet people often do not realize how common concussions are in everyday life, and seldom does the public hear about what happens in the aftermath of concussions – how long the road to recovery can be and what supports healing. Concussions are important to understand, not only for recovery, but also for the insights that the science of recovery can bring to brain health.

I am a speech language pathologist and an instructor in physical medicine and rehabilitation. I specialize in brain injury rehabilitation, with experience ranging from coma recovery to concussion care.

Treating problems tied to head injuries is complex. This is, in part, because it is not possible to directly examine the brain of a living person and because every brain injury is unique. Many aspects of health, both pre- and post-injury, affect recovery. In treating brain injuries, I work to translate this specialized science for each patient and their unique situation.

Brain Injuries Take Many Forms

While people commonly think of athletes when it comes to concussions, sports-related concussions are just one type of mild brain injury seen in health care practice. Concussions can also result from abusive head trauma, blast exposure, car accidents and falls.

The severity of a brain injury is diagnosed based on symptoms, brain imaging and a neurologic exam. Concussions are characterized by a lack of clear tissue damage seen on brain images like an MRI and by the length of time that a person loses consciousness – defined as between zero to 30 minutes.

In addition, a significant portion of concussions may not be identified or formally diagnosed at all. Even if you do not lose consciousness at the time of an injury, you could still have a concussion. Confusion, sensitivity to noise and lights and even changes to sleep and mood are common symptoms. But often, these signs may be misunderstood as signs of stress or shock during traumatic events, such as a car accident. Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.

People who don’t feel that they have returned to normal after a concussion may need further treatment. Many report chronic symptoms that linger beyond the typical three-month recovery – a condition known as post-concussive syndrome. Around 10% of those who suffer a concussion experience post-concussive syndrome, although differences in how this problem is defined and recorded leads to highly variable estimates across studies.

So how does having a concussion affect the brain over time?

The links between concussion and dementias such as chronic traumatic encephalopathy, or, more generally, the relationship between a brain injury early in life and later brain diseases, are not yet clear. This uncertainty should not stop people from finding a path forward and taking strides to support their own brain health.

Brain ‘Detours’

After recovering from a brain injury, patients want to understand how to minimize further risk to their brain, which is all the more important since prior injury puts the brain at greater risk for further injuries.

Researchers and medical providers have learned that after injury the brain can change and “rewire” itself at a cellular level over the life span – a process called neuroplasticity. Brain cells, called neurons, join to form electrical pathways that power activity within the brain.

In addition to other repair processes, neuroplasticity supports damaged brain areas to reconnect injured routes or find “detours” to restore brain function. This means that in recovery, the brain can literally find a new way – or make one – to regain critical abilities.

Neuroplasticity also offers insight into why each brain injury is unique. Following a concussion, therapists focus on detailed evaluations and patient interviews to identify affected areas and to design an intervention.

While the general map of brain regions and their associated functions is standard, individual variability is common. Brain injuries from the same cause of injury, via similar force and intensity of impact and affecting the same location of the brain, can lead to very different symptoms in different people.

While the brain is fully developed by the time people reach their early 20s, neuroplasticity continues well beyond this point. Researchers have seen neuroplastic change during the life span in both the white and gray matter that form brain tissue. The remapping of brain pathways that occurs in late-life injuries, such as a stroke, is one strong piece of evidence to suggest there may be no specific “end date” to the brain’s capacity to restore its internal connections.

Importantly, fuller density of brain cells is thought to create a buffer that is protective against damage due to injury and aging. This extra “bandwidth” is referred to as cognitive reserve. Broadly speaking, higher levels of baseline cognitive reserve have been linked to genetics, educational attainment and health factors.

Neuroplasticity is one process that research shows is critical to maintaining these reserves throughout life.

Building Brain Health

Cognitive reserve is crucial to brain health both before and after a concussion. Studies show that higher levels of cognitive reserve may lessen your risk for prolonged problems after a concussion.

In addition, injuries that occur during childhood and late life may present different challenges in recovery linked to the brain’s cognitive reserves and overall health. For this reason, screening tools for concussion often probe a person’s medical history prior to the event.

Keeping up cognitive reserves likely maintains healthy brain connections that can help us age better. Bilingualism, maintaining an active social life and even going to museums are linked with lower rates of dementia. These studies support that brain activity is good for brain health and it is triggered by many things, including thinking, learning and engaging with the world around us.

Just as there is no one-size-fits-all brain injury, there is also no single path toward brain health.

Advanced brain imaging to detect concussions is not available in standard clinical settings, so clinicians rarely have clear road maps for rehabilitation. But getting optimal sleep, avoiding excessive drinking or other toxic substances and leading a physically and mentally active life are core tenets of brain health.

Finally, the brain does not exist in isolation. Its health is connected to other parts of the body in many ways. Therefore, doctors recommend treating medical conditions that directly affect our brain health and that reduce brain aging, such as high blood pressure,sleep apnea,migraines and even hearing loss.

Brain health is unique to each person, and brain injury treatment depends on your individual lifestyle and health risks. Strategies to treat specific symptoms vary and should be designed with the help of medical specialists. But brain health and cognitive reserve provide a common direction for everyone. Living an active lifestyle – physically, mentally and socially – can drive neuroplasticity and maintain the brain.

Studies of healthy people offer insights into how individual brains are shaped through everyday activities. For instance, research finds that expert musicians have denser sound-processing regions in their brains. The brains of cab drivers have greater development of spatial memory areas. Even military fighter pilots have been shown to have denser tissue in regions connected to strategic thinking.

These startling discoveries teach us that what we do every day truly matters to brain health. For all of these reasons, brain researchers commonly use the phrase “neurons that fire together, wire together” to describe how the brain’s connections change shape associated with repeated patterns of the electrical firing of brain activity.

While many questions remain to be answered, it is well established that the brain can be shaped throughout life. With this knowledge in mind, we can tend to it with greater care.

Hilary Diefenbach, MA, is a licensed Speech Language Pathologist at the Marcus Institute for Brain Health and an Instructor at the University of Colorado School of Medicine. Hilary specializes in brain injury rehabilitation for adults.

This article originally appeared in The Conversation and is republished with permission.