Pain And Emotion

Although mainly about the effects of emotion on reason, ‘Descartes’ Error‘ by Antonio Damasio contains a few fascinating nuggets on pain. He distinguishes 2 components to pain:

• Sensory perception from skin, mucosa, muscle, organ, etc. – the nerve endings stimulated in an area of the body lead to a ‘pain image’, a temporary representation  of body change in the brain. This is no different from any other kind of body perception and if it were all, we would not be inconvenienced.
• Emotion and feeling – it’s from these body-state changes that the unpleasant feeling of suffering is formed. “Suffering puts us on notice and offers us the best protection for survival, since it increases the probability that individuals will heed pain signals and act to avert their source or correct their consequences.“

Damasio’s views on emotion/feeling and pain are probably the result of his experience with the eminent Portuguese neurosurgeon Almeida Lima. Lima worked closely with Portuguese neurologist Egas Moniz. Together they developed prefrontal leucotomies, later known as lobotomies, during the 1930s. In 1949 Moniz received the Nobel Prize in medicine for his work. Damasio recalls following Lima on a pre-operative visit of a patient with trigeminal neuralgia, a condition that causes severe facial pain. “He was crouched in profound suffering, almost immobile, afraid of triggering further pain. Two days after the operation, when Lima and I visited on rounds, he was a different person. He looked relaxed, like anyone else, and was happily absorbed in a game of cards with a companion in his hospital room. Lima asked him about the pain. The man looked up and said cheerfully “Oh, the pains are the same, but I feel fine now, thank you.” Clearly, what the operation seemed to have done, then, was abolish the emotional reaction that is part of what we call pain. It had ended the man’s suffering.”

Obviously, lobotomies are extreme measures and they can cause serious side effects. This is certainly the reason fewer and fewer operations are being performed. Nowadays these operations are called psychosurgery and they have become much more precise. The important point is Damasio’s view on the link between pain and emotion. It corroborates a lot of the research being done on chronic pain. Hence, the importance of addressing the emotional part. Fortunately, there are now safer more humane ways of doing it, like relaxation, meditation, cognitive behavioural therapy, neuro-linguistic programming and hypnosis.

Is Back Pain Genetic?

There’s been a lot of talk in the press (BBC, The Telegraph, Yahoo, Medical News Today, etc.) this week about finding the gene that causes back pain. So now back pain can be added to a host of other inherited conditions such as obesity, depression, cancer and diabetes. Before I give my opinion, I’d like to specify exactly what recent research has found. The study was carried out at King’s College London and was published this month in the Annals of Rheumatic Diseases. They found an association between the PARK2 gene and lumbar disc degeneration (LDD). The PARK2 gene switches off in people with LDD. LDD is the progressive dehydration of lumbar discs leading to disc space narrowing and osteophyte (bony spurs) growth. It is thought to be a common cause of low back pain (LBP).

It’s interesting to note however, that only 5 % of the population is affected by LDD but over 80% of people will have an episode of LBP at some time in their lives. Also, lots of people diagnosed by MRI scan with LDD have not experienced low back pain…strange? The obvious conclusion is that most LBP is not caused by LDD. Now, let’s look more closely at the relationship between the PARK2 gene and LDD. Does having the PARK2 gene automatically lead to disc degeneration? No! The PARK2 gene has to be switched off for that to happen. What switches it off? That there is the million dollar question, and it hasn’t been answered to satisfaction. The researchers have alluded to environmental factors such as lifestyle and diet. This is starting to sound familiar…could this be the old ‘nature vs nurture’ debate again?

Epigenetics explains how genes can be switched on and off. It’s the study of mechanisms by which the environment controls gene activity. “These mechanisms can enable the effects of parents’ experiences to be passed down to subsequent generations eg. paternal grandsons of Swedish men who were exposed during preadolescence to famine in the 19th century were less likely to die of cardiovascular disease, if food was plentiful, then diabetes mortality in the grandchildren increased” (Wikipedia).

Being told that we have a gene for x, y or z disease can lead to a helpless condition where we believe we have no control over what happens to us and so we gloomily go down a predestined path. “I can’t do anything about it, it’s in my genes.” Incidentally, self-fulfilling prophecies can come into play here. On the other hand, epigenetics puts us firmly in the driver’s seat. We can control our environment by controlling what we do, how we think, what we eat, drink, etc. It empowers us to write our own scripts. Gattaca is a beautiful example of this…I know it’s only a film but wasn’t it good!

Coming back to LBP, nothing has changed. Acute back pain is often caused by physical factors such as poor lifting technique, twisting, and prolonged sitting. Whereas with chronic back pain, there is the added contribution of mental, emotional and social factors. The good news is that whether it is acute or chronic, there are lots of things that can be done to prevent, treat and manage low back pain.

Mindfulness Changes Pain

I read an interesting passage in ‘Mindfulness’, Ellen Langer’s insightful book on social psychology.

“Patients are often certain that pain is inevitable in a hospital. Caught in such a mindset, they assume that, without the help of medication, pain cannot be controlled. In our experiment, we tried to learn whether people could control their experience of pain by putting it in a different, more optimistic context.

Patients who were about to undergo major surgery were taught to imagine themselves in one of two situations: playing football or preparing for a dinner party. In the midst of a rough skirmish on the football field, bruises are hardly noticed. Similarly, cutting oneself while rushing to prepare dinner for ten people who will be arriving any minute might also be something one would hardly notice. In contrast, a paper cut suffered whilst reading a dull magazine article quickly becomes the focus of attention. Through examples of this sort, participants in the study were taught that, rather than being inevitable, much pain we experience appears to be context-dependent.

Hospital staff, unaware of our hypothesis, monitored the use of medication and the length of stay for the participating patients in the experimental group and in the control groups. Those patients who were taught to reinterpret the hospital experience in nonthreatening ways took fewer pain relievers and sedatives and tended to leave the hospital sooner than the untrained patients. The same hospital experience seen through psychologically different eyes is not the same experience, and the difference could be measured in lower doses of medication and quicker recoveries. This reappraisal technique effectively loosened the hospital mindset and, by showing that pain was not a certainty, gave the participants more control over their convalescence.”

This experiment clearly demonstrates that changing our mindset can change our experience of pain!

Acupuncture NICE For Headaches

The National Institute for Health and Clinical Excellence (NICE) has released its first clinical guideline on how to diagnose and manage headaches. It differentiates 4 types of headache: tension-type headaches, migraines, cluster headaches and medication overuse headaches. NICE recommends acupuncture as a treatment option for tension-type headaches and it says we should “consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache”.

“All limitations are illusions“

Harry Houdini

“Man is disturbed not by things,

but by the views he takes of them.’

Epictetus

BBC Horizon’s – Eat, Fast And Live Longer

Another great programme from BBC Horizon presented by Dr Moseley. He starts off the programme by following the oldest man to complete the London marathon…a 101 yr old sikh who is healthy and takes no medication…the typical 65 yr old european takes 6 pills a day! The centenarian attributes his good health to his diet and more specifically his small portion size…about half of a normal adult”s.

This is not the first time that caloric restriction has been linked to longevity. In the 1930s, during the great depression in the US, although there were widespread food shortages…surprisingly life expectancy increased by 6 years. During the same period scientists at Cornell University found that animals on restricted diets lived longer.

Dr Moseley had a keen personal interest in the subject because of the threat of disease due to elevated blood sugar and cholesterol. He traveled the US speaking to the most eminent specialists in the field in a quest for a solution to his health problems. His first port of call was Professor Luigi Fontana from Washington University and Salerno Schools of Medicine. Prof Fontana advised a diet low in calories but high in nutrients and introduced Dr Moseley to Joe. Joe was in his 50s and had been on 1900 kcal/day for about 10 years. His body fat was 11.5% whereas Dr Moseley”s, also in his 50s, had a body fat % of about 27. Although the benefits were clear, Dr Moseley wanted to understand the mechanism in the hope of being able to draw the benefits without having to do any of the hard work! This is one of the reasons I like his programmes…his attitude is typical of the average european (or american)…we want results quickly, with as little effort as possible…sound familiar?

He then met up with Professor Valter Longo at the University of Southern California. Prof Longo showed him a special mouse…about half the size of a normal mouse…but incredibly it had a lifespan that was 40% longer…the equivalent of 120 human casino jameshallison years! The mouse had been genetically modified to have low levels of the a growth hormone called Insulin-like Growth Factor 1 (IGF1). IGF1 is thought to be the link between calorie restriction and longevity. There are about 350 people worldwide who have genetically inherited low levels of IGF1. Their condition is named Laron syndrome and although some of them smoke and eat what they want, amazingly they don”t get diabetes or cancer! Low levels of IGF1 seem to increase cell repair and decrease cell division (which probably accounts for their extremely small stature).

Protein has been found to increase our metabolism and put us in “go-go” mode but the downside is that it decreases cell repair. Three things can help decrease levels of IGF1: decreasing calorie intake, decreasing protein intake and lastly, the most effective way…is by fasting. Fasting can dramatically reduces levels of blood glucose and IGF1 within as little as 24 hrs. Obviously fasting can be dangerous and should only be undertaken if in good health and under close medical supervision. So Dr Moseley decided to give it a go for 3.5 days. He only allowed himself water, black tea and a 50 kcal soup each day. As expected, his blood sugar decreased significantly and his IGF1 levels halved. Unfortunately, the effects are only temporary and one would need to decrease protein intake and fast every couple of months to maintain changes…not for Dr Moseley, so he continued his search…

Dr Krista Varady from the University of Illinois at Chicago had a much more palatable proposition…eat as much of whatever you want on one day and eat a reduced amount of whatever you want the following day…feed day, fast day, feed day, fast day, etc. It”s called Alternate Day Fasting (ADF). On the fast days women are advised to eat 400-500 kcal and men 500-600 kcal. Preliminary trials with overweight subjects are showing promising results including weight loss, lower levels of bad cholesterol and fats in blood and decreased blood pressure.

Lastly, Dr Moseley paid a visit to Dr Mark Mattsen from the National Institute on Aging in Baltimore. He has conducted animal experiments on intermittent fasting and has found that it postpones the development of Alzheimer”s and senile dementia like diseases. Sporadic bouts of hunger seem to trigger the growth of new neurones! In evolutionary terms, this would have provided a survival advantage in times of famine. Intermittent fasting has better effects on the brain than daily calorie restriction. Dr Mattsen suggested alternating 5 days of normal eating with 2 days of fasting. So Dr Moseley gave it a go for 5 weeks. On the normal days her took in around 200 kcal and on the fast days he ate about 600 kcal. Please bear in mind that normal calorie intake is based on sex, height, weight and activity. The results were extremely impressive. He managed to lose 1 stone and decrease his body fat from 27% to 19%! His blood sugar levels decreased to within normal limits, his IGF1 levels halved, his total cholesterol decreased and his good cholesterol increased. I assume that although he could have eaten whatever he wanted, he was sensible about it.

Dr Moseley ended the programme by saying that it was “the most interesting journey that I”ve ever been on…and I”ve never said that before”.

Healthy Water For A Longer Life

Last year I wrote an article on hydration, the signs of dehydration and how much water we need to drink each day. We now know how much water to drink but what water is best? I found a great little book called “Healthy Water for a Longer Life” by Martin Fox. It reviews an extensive body of research carried out on the effects of the quality of water on health. Although it was published in 1986, I don’t think there exists a more comprehensive book on the subject. What follows is a summary of the main points.

High levels of water hardness and total dissolved solids have been linked with decreased cardiovascular disease. Hard water is water that has high levels of calcium carbonate or magnesium carbonate. In areas with hard water, you’ll notice your kettle fur up pretty quickly and in areas with soft water you’ll find it harder to wash off soap when showering. British studies have suggested hardness of at least 170 mg/l for health benefits. In the north of England, the neighbouring towns of Scunthorpe and Grimsby drank the same water for years. Scunthorpe then softened its water from 448 mg/l to 100 mg/l and Grimsby continued with the same water as before. This led to a striking increase in cardiovascular disease in the town that softened its water!

No correlation between sodium levels in water and hypertension or mortality has been found. This is probably because only 10% of our sodium intake comes from water and the rest comes from food. So avoiding processed foods and not salting our food has a bigger impact on our health.

Increased water hardness, increased total dissolved solids, increased pH and increased silica (SiO2) are each linked to decreased risks of cancer.

Fluoride is thought to prevent caries but its use is controversial due to the risk of cancer, genetic damage and birth defects. Water fluoridation has been abolished in most of Europe but continues in some parts of North America. High levels of water hardness and total dissolved solids can negate the deleterious effects of naturally occurring fluoride. Studies of dental caries in primitive groups have found that a healthy unrefined diet leads to healthy teeth.

Chlorination of water has saved countless lives by killing harmful bacteria but it has also led to an increase in atherosclerosis, heart disease and cancer. This is thought to be caused by a release of free radicals.

Animal experiments have shown that hard water provides protection from potentially harmful agents such as cadmium, lead, chlorine and dietary fat. An interesting calcium-chlorine relationship has been found. Pigeons were fed a diet that contained only 80% of the recommended daily allowance (RDA) of calcium. Half the birds were given unchlorinated water and the rest drank water that contained 10 mg/l of chlorine. Three months later the pigeons that drank chlorinated water had blood cholesterol levels that were 50% higher than the group that drank unchlorinated water. Further tests showed that pigeons given a normal diet show no differences in cholesterol levels between those that drink chlorinated water and those that don’t. When 10% lard is added to a calcium deficient diet, pigeons that drink unchlorinated water only have a minor increase in cholesterol but those that drink chlorinated water have cholesterol levels that increase about 3 fold!

Some people claim that demineralised water is better for health but there is no rationale or scientific study to support its benefits. In fact, the reverse is true…soft water is hazardous to health. Minerals with beneficial effects are: silica, magnesium, chromium, lithium, vanadium, calcium and zinc. Interestingly, mineral absorption is greater from drinking water than from food and protein enhances the absorption. If essential elements are present in water, there is less absorption of non-essential (toxic) elements.

Finally, which water is best? It has to have a presence of essential minerals and an absence of harmful minerals and compounds. Tap water may be suitable but one would have to verify its composition with the water company…a water filtration system may be required to remove harmful compounds (inorganic and organic)…the quality of filtration systems varies widely…and one has to be careful to avoid a build up of bacteria within the filtration unit…

By far the easiest option is to select bottled mineral water that satisfies the following criteria:

• approximately 300 mg/l of total dissolved solids
• around 170 mg/l hardness (calcium carbonate)
• an alkaline pH (over 7)

Cheers!

Acupuncture Helps Nerves Regenerate

Several experiments have been conducted on animals to study the effects of acupuncture or electroacupuncture on nerve injuries. Here are some of the results and conclusions:

• acupuncture increases the survival of damaged neurons
• electroacupuncture increases the number of nerve fibres
• electroacupuncture increases axon density and blood vessel area
• electroacupuncture improves nerve conduction speed
• electroacupuncture improves the function of de-innervated muscle tissue

So those are the effects on rats, rabbits and frogs…but what about humans? Well, a study conducted in Germany at the Heildelberg School of Chinese Medicine and published in the European Journal of Neurology showed some promising results. Forty seven patients with peripheral neuropathies of unknown cause were assigned to either an acupuncture group or a control group (the control group received the best medical care but no specific treatment for peripheral neuropathy). The patients were evaluated over a year by nerve conduction studies.

Over three-quarters of the acupuncture group improved. These results are even more impressive when we realise that the natural progression of the neuropathies, as shown by the control group, was one of gradual deterioration.

The overwhelming data suggests that acupuncture can help promote nerve regeneration and this remains true whether the nerve problem results from injury or some undefined cause.

Nerve Injuries

Nerves are cable-like structures that send information between the central nervous system (spinal cord and brain) and the target organs (internal organs, skin, muscles, joints, etc). A nerve if formed of bundles of axons surrounded by layers of connective tissue. Nerves are responsible for reflexes, sensation and muscle contractions. Pain, tingling, numbness and muscle weakness are tell-tale signs of nerve pathology.

The most common nerve injuries are:

• Stretch-related injuries: these are encountered when traction forces exceed the nerve’s capacity to stretch eg. Erb’s Palsy is an injury to the brachial plexus during childbirth
• Lacerations: these are caused by knifes, glass and other sharp implements
• Compression injuries: these can either be caused by external forces, as in the “Saturday Night Palsy” or “Honeymooners Palsy”  which is a radial nerve compression generally preceded by arm pain to a degree that only excessive alcohol or love would drive a person to keep the arm in such an uncomfortable position; or internal forces eg. carpal tunnel syndrome and sciatica and it’s associated neurological symptoms. The latter is often referred to as a nerve entrapment or “trapped nerve”.

Seddon was the first to classify nerve injuries in 1943. His classification is probably the simplest and is still used today:

• Mild injuries (Neurapraxia): temporary loss of conduction at injury site leading to sensory or motor problems; no damage to axon or surrounding sheath and connective tissue; full recovery within days or weeks.
• Moderate injuries (Axonotmesis): temporary loss of conduction below the site of injury leading to sensory or motor problems; complete disruption of axon and surrounding myelin sheath below the level of injury but connective tissue encapsulations are preserved; because the tunnels formed by connective tissue are preserved, the sprouting axon shoots are able to eventually reconnect to the target organs; the process can take some time as nerves regenerate at a speed of about 1mm/day (0.5-9mm/day).
• Severe injuries (Neurotmesis): temporary or permanent loss of conduction below the site of injury leading to severe sensory, motor and autonomic problems; partial or complete disruption of the entire nerve, including the connective tissue encapsulations; because of the discontinuity in the connective tissue tunnels and the formation of scar tissue, recovery without surgery is unlikely; also, after about a year of denervation, the sprouting axons are no longer able to connect to receptor sites on target organs such as muscle, sensory receptors may survive for many years.

In summary, and this may be obvious, nerve injuries that leave the connective tissue tunnels intact have a greater likelihood of leading to full recovery. Although it may take several months or even up to a year for this to happen. This type of injury usually results from compression injuries or mild stretch-related injuries. Severe stretch-related injuries and lacerations are more serious because they usually damage the connective tissue tunnels. This requires surgery and often leads to incomplete recovery.

Next week we’ll see how acupuncture can promote the regeneration of nerve injuries.