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Gout – Definition, Diagnosis and Treatment

DEFINITION

Gout is a term used to refer to a group of disease states caused by tissue deposition of monosodium urate due to prolonged hyperuricemia. Clinical manifestations of gout include acute and chronic arthritis, soft tissue inflammation, tophus formation, gouty nephropathy, and nephrolithiasis. Untreated hyperuricemia in patients with gout may lead to chronic destructive deforming arthritis

ETIOLOGY

Gout is induced by inflammation from mono- sodium urate (MSU) crystal deposition. The primary risk factor for MSU deposition is hyperuricemia.

Hyperuricemia and gout develop from excessive uric acid production, a decrease in the renal excretion of uric acid, or both.

Primary hyperuricemia results from an inborn error of metabolism and may be attributed to several biochemical defects.

Secondary hyperuricemia may develop as a complication of acquired disorders (e.g., leukemia) or as a result of the use of certain drugs (e.g., diuretics). Consumption of alcohol, especially beer, increases the risk of gout, and fructose-rich beverage intake is associated with hyperuricemia.

Key Components of Gout Flares

  • Marked tenderness and swelling of affected joint
  • Acute onset with maximum pain in 4-12 hr
  • Recurrent pattern of similar attacks
  • Marked impairment of physical function
  • Resolution of symptoms within 3-14 days

PHYSICAL FINDINGS & CLINICAL PRESENTATION
ACUTE GOUT:

  • Rapid onset of pain and swelling and erythema of a distal joint and/or periarticular soft tissue. Summarizes key components of gout flares
  • May present as monoarthritis of any joint. Acute gout of the first metatarsophalangeal (MTP) joint is known as podagra
  • 10% to 15% of attacks are polyarticular
  • Spontaneous resolution occurs over days to weeks

CHRONIC TOPHACEOUS GOUT:

  • Insidious onset of painless arthritis and soft tissue swelling
  • Distal small joints characteristic
  • May be confused with nodal osteoarthritis

DIFFERENTIAL DIAGNOSIS OF ACUTE GOUT

  • Infectious arthritis
  • Cellulitis
• Pseudogout
  • Trauma

DIFFERENTIAL DIAGNOSIS OF CHRONIC GOUT

  • Osteoarthritis (especially nodal OA in women)
  • Rheumatoid arthritis
  • Psoriatic arthritis
Section II describes the differential diagnosis of acute monoarticular and oligoarticular arthritis.

WORKUP

Arthrocentesis and examination of synovial fluid

LABORATORY TESTS

  • Uricacid: All patients with gout are hyperuricemic at some time, but during an acute attack the serum uric acid may be normal or low.
  • Synovial aspirate: usually cloudy and markedly inflammatory in nature. Urate crystals in fluid are needle-shaped and strongly negatively birefringent under polarized microscopy
  • CBC: mild leukocytosis often present
  • Inflammatory markers: ESR and CRP often elevated

IMAGING STUDIES

  • Plain radiography for diagnosis and evaluation. Not generally indicated in typical gout presentation
  • No typical findings in early gouty arthritis but late disease is associated with characteristic punched-out marginal erosions and overhanging edges

TREATMENT OPTIONS FOR ACUTE GOUT

  • Nonsteroidal anti-inflammatory medication

– Indomethacin 75 mg bid
C Ibuprofen 800 mg tid

– Naproxen 500 mg bid

– Celecoxib 800 mg, then 400 mg/day

  • Low-dose colchicine (less toxic and as effective as traditional high-dose colchicine): 1.2 mg colchicine PO, followed by 0.6 mg PO 1 
hr later.
  • Intraarticular corticosteroid injection (treatment of choice for monoarticular large joint attack): Triamcinolone hexacetomide 40 mg or equivalent for knee
  • Systemic corticosteroid therapy: Prednisone 40 mg PO for 3 days, then taper over 10 days (effective and safe, but evidence is lacking)

NONPHARMACOLOGIC THERAPY

Lifestyle and dietary modification may be effective in highly motivated patients. Recommendations include reducing ingestion 
of red meat, kidney, liver, yeast extract, shellfish, and overall protein along with restricting alcohol intake. These recommendations should be attempted only in patients with modestly elevated uric acid, as dietary modification can only lower uric acid 1 mg%. Discontinuation of diuretic therapy may help.

PHARMACOLOGIC TREATMENT OF SYMPTOMATIC HYPERURICEMIA

ALLOPURINOL: Allopurinol is very effective and safe when used properly. Correct dosing and patient compliance are essential elements in the prevention of erosive and tophaceous gout. Patients with renal insufficiency are at increased risk for allopurinol hypersensitivity, which manifests as fever, rash, and hepatitis occurring most commonly in the first 3 mo of therapy. The rash may progress to life-threatening toxic epidermal necrolysis if not recognized early.

Traditionally, therapy with allopurinol is initiated several weeks after the acute attack has resolved. However, adding allopurinol at initial presentation may improve long-term compliance without reducing the efficacy of acute treatment. The initial dose should be low (≤100 mg/day depending on creatinine clearance) in patients with renal insufficiency and those with very high uric acid levels. High initial doses are associated with increased incidence of allopurinol hypersensitivity. The serum uric acid should be reevaluated after 4-6 wk of therapy, and the allopurinol dose adjusted to reduce the serum uric acid to less than 6 mg%. The most common therapeutic dosage of allopurinol is 300 mg/day, but dose may be increased by 50-100 mg every two to three weeks until the target serum uric acid level is achieved. There is evidence that increasing allopurinol doses in patients with renal insufficiency does not result in significant toxicity, but concurrent use with statins and colchicine is associated with a higher incidence of adverse effects. Some authors have reported using doses as high as 800 mg daily without excess toxicity.

FEBUXOSTAT: Novel xanthine oxidase inhibitor that has been shown to be more potent than allopurinol 300 mg daily for reducing serum uric acid. The chemical structure of febuxostat is different from allopurinol, making cross-reactive allergy unlikely. The metabolism of febuxostat is primarily hepatic, which obviates the need for dose adjustments due to renal insufficiency. Some cases of hepatic toxicity have been reported, and it is recommended that liver function tests be monitored periodically. Febuxostat may help preserve renal function in patients with chronic kidney disease (CKD) but has not been tested in patients with severe renal failure.

The primary indication for febuxostat is demonstrated allergy to allopurinol. The cost of febuxostat may be as much as 40 times that of allopurinol.

BENEMID AND SULFINPYRAZONE: These uricosuric agents may only be used in patients with good renal function and urinary uric acid less than 600 mg in a 24-hr collection. Compliance is poor due to necessity of taking drugs more often than once daily

PEGLOTICASE: Intravenous pegylated uricase was approved by the FDA in 2010 for treatment of severe refractory tophaceous gout. It is a pegylated recombinant mammalian uricase that rapidly degrades urate when given intra- venously. Use is limited by very high cost and significant toxicities including frequent gout flares and anaphylaxis.

PATIENT/FAMILY EDUCATION

It is essential that patients, families, physicians, and other members of the health care team appreciate the importance of compliance with a daily allopurinol regimen if recurrent flares and progression to chronic arthritis and tophi are to be avoided. Allopurinol should be discontinued only for symptoms suggesting the hypersensitivity syndrome. It should be continued during flares, medical illnesses, and surgical procedures.

REFERRAL

  • Rheumatologist if diagnosis is not clear or therapy is complicated
  • Podiatrist for management of pedal complications
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My Passion for Distraction- Pain News

By Cynthia Toussaint I’ve been using distraction as my #1 painkiller for 34 years without knowing it. Now that I’ve come to  understand the power of intuitive healing, I want to shout it to the world. After getting CRPS from a ballet injury at age 21, I thought I had gangrene and my purple, burning…

My Passion for Distraction

By Cynthia Toussaint

Cynthia Toussaint

Cynthia Toussaint

I’ve been using distraction as my #1 painkiller for 34 years without knowing it. Now that I’ve come to  understand the power of intuitive healing, I want to shout it to the world.

After getting CRPS from a ballet injury at age 21, I thought I had gangrene and my purple, burning leg would be amputated. Perhaps the biggest mystery back then was not my excruciating, undiagnosed pain, but the fact that when I got on stage in a Vegas illusion act complete with tigers and fire, I didn’t feel it. When I was in front of the audience, it was as though someone had flipped my pain switch off.

Problem was, when I wasn’t on stage I couldn’t walk let alone dance. When the pain spread and I had to quit the act, I listened to Prince – a LOT! His artistic genius gave me an adrenaline high. Don’t get me wrong, I still had pain. But listening to my all-time favorite artist at his peak often turned a level 9 or 10 down to something I could survive. At least temporarily.

Back in those days my mom was in tune with distraction therapy more than me. When she heard my moans and cries, she automatically started cooking. I was shocked one day when she confessed that my pain was always better when I was eating something tasty. How could that be?

Years later after the CRPS spread throughout my body and I was bedridden, my life became pretty damn small. But I still had normal desires – and my life partner John and I made love often. I was amazed that my tortured body could still feel pleasure. Those afternoon delights gave me ecstatic relief.

Founding and leading the nonprofit For Grace – where we empower women in pain – continues to be my healthiest, most meaningful distraction. Waking most mornings to projects stacked high, phone calls and emails to return, meetings to attend and interviews to give doesn’t allow me to focus completely on my pain. When I’m fully engaged in work, this healthy distraction sets up a barrier to the pain-is-me identity, a trap too easy to fall into.

Probably the longest, most focused and challenging project at work was writing with John our pain experience as a book. For nearly seven years, we huddled with co-writers, agents, lawyers, publishers and our editor. During this often grueling, yet liberating, process, I noticed a subtle improvement in my function and reduction in pain. I used my wheelchair less and began yearning to get into a swimming pool.

When I finally made the splash, it was like moving through medicine – but with no side effects, except for gaining a new community and a better shape. In fact after no aerobic exercise for 19 years, I was within weeks swimming a mile. In no time I recaptured other passions that CRPS had long before ripped out of my grasp. I was singing, traveling and playing the piano.

The doctors called my partial remission a miracle, inexplicable. However I knew it had come about as a result of my years of healthy distraction forged by narrative therapy. But how did it work – and why?

That’s what we’re going to learn at For Grace’s 9th annual Women In Pain conference on September 23rd in Los Angeles (a free, live webcast will be available at forgrace.org.) Speakers will unveil the research that explains how positive things that take us away – allowing us a mini-vacation if you will – also lowers our pain level.

We’ll discover many strategies and actions that can help us get away from our pain including good sleep, healthy sex, guilty TV pleasures and expressive arts. With our Hawaiian theme, including a hula dance troupe led by a woman in pain, we’ll be reminded that fun and play can still be a part of our lives.

I understand too well the suffering, fatigue and isolation that defines chronic pain. In fact, in many ways this has been the most painful year of my life.

But come September 23rd, I’m grabbing my passport, slathering on suntan lotion and going on vacation. I hope y’all will join me. Aloha!

Source Nationalpainreport.com
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How Our Stuff Might Be Making Us Sicker- Pain News

Donna Gregory Burch Lately I’ve been wondering if our material possessions could play a role in our fibromyalgia symptoms. My ruminating started a few months ago when the KonMari craze was at its peak. My YouTube feed was flooded with stay-at-home moms holding their ice cream scoops and lacy camisoles and asking, “Does this spark…

How Our Stuff Might Be Making Us Sicker

Donna Gregory Burch

donnasnowday

Donna Gregory Burch

Lately I’ve been wondering if our material possessions could play a role in our fibromyalgia symptoms. My ruminating started a few months ago when the KonMari craze was at its peak. My YouTube feed was flooded with stay-at-home moms holding their ice cream scoops and lacy camisoles and asking, “Does this spark joy?” Seeing t-shirts folded into little rectangular packages and then filed vertically in a drawer fed into my obsessive-compulsive nature. Some of Kondo’s teachings do seem a little silly to me (like emptying your purse every night), but I can appreciate her overall intent. I’ve always tried to live by the rule that everything in my home has to be either beautiful (i.e. brings joy) or useful in some way.

Then I started binge-watching HGTV’s “Tiny House Hunters” where potential homebuyers tour teensy, weensy homes for sale – some of them less than 250 square feet! More than once, my hubby and I looked at our living room and realized that was some people’s ENTIRE house. We wondered aloud if we could ever live in a space that small. We’d probably end up killing each other, we concluded, but I think we both came to the realization that our 2,300-square-foot home is way too big for our needs. We love our home, and we don’t have any plans to sell, but if I’m being honest with myself, sometimes it feels like a big energy drain. Too many rooms to clean. Too much stuff to maintain. Too many closets to organize. Just too much …

(To be clear, I am not a hoarder. I’ve always been a neat, organized person, and my hubby and I probably own less than most households.)

Those of us with fibromyalgia are usually sensitive to bright lights, strong smells, abrasive sounds and other external stimuli. But I think visual clutter can be just as stressful, and lately I’ve felt overwhelmed by my ever-growing to-do list and all of our physical possessions. It just feels like too much to maintain.

As it turns out, I’m not alone in this internal struggle. According to TheBalancedLifeOnline.com:

“Studies show a direct link between the amount of physical possessions in a house and the stress level of the female homeowner. One study done at UCLA found that the more stuff was in a woman’s house, the higher her level of stress hormones. This same study also found that women subconsciously relate how happy they are with their home-life and family to how they feel about their homes. So the more clutter and chaos in the home, the less happy the woman is with her family and her life.”

We all know stress is a common trigger for fibromyalgia symptoms, so could our possessions be contributing to our illness?

They definitely could be adding to our cognitive difficulties. A Princeton study found that visual clutter affects one’s ability to focus and process information. As if our brain fog wasn’t already working against us!

And then there’s the obvious: It takes time, energy and money to clean and maintain all of our stuff. Battling fibromyalgia and Lyme disease, I have limited mental/physical energy and financial resources. Do I really want to waste those on managing my material possessions? The easy answer is no.

So, for the past few months, whenever I have the energy to do so, I’ve systematically been going through every closet, drawer and bin in my home and downsizing. I’ve revisited some areas two, three, even four times, continuing to pare down to essentials. Do I really need that hairdryer diffuser? I haven’t used it in years because it makes me look like Richard Simmons. Out it goes. Do I need the Boyd’s bear my hubby gave me for Valentine’s Day three years ago? Yes, it’s cute, but I stopped collecting stuffed animals decades ago, and it’s just sitting in a box getting dusty. Maybe it would spark joy for some little boy or girl…

I’ve also been trying to figure out ways to pare down my daily tasks and decision-making. I’ve read that mega-successful people like the late Steve Jobs choose to wear the same outfit every day. Why? Because it streamlines decision-making, so they can channel their energy to more important tasks. I’ve been watching capsule wardrobe videos on YouTube and wondering if I could feel joyful with a wardrobe of all black and grey. Probably not, but I am thinking seriously about cutting my closet down to just a few coordinating tops and bottoms. Sometimes it seems like our stuff generates too many choices, and frankly my foggy brain doesn’t feel like making that many decisions anymore. I just want simple, easy, uncluttered, uncomplicated. I don’t want to use my precious mental energy figuring out what shirt goes with which pair of shorts, and where are the matching shoes and accessories.

I’m determined to get rid of the unessential in our home – both physical and mental. We have a storage room on our third floor, and it’s half full of stuff that I’ve priced and boxed up for an upcoming yard sale. What’s left will be donated to charity. I’m hoping my stripped down closets and kitchen cabinets will become less of a stressor, and that in turn will help calm my overactive nervous system.

Maybe one day I can talk my hubby into building a semi-tiny home of our very own…

Donna Gregory Burch was diagnosed with fibromyalgia in 2014 after several years of unexplained pain, fatigue and other symptoms. She covers news, treatments, research and practical tips for living better with fibromyalgia on her blog, FedUpwithFatigue.com. Donna is an award-winning journalist whose work has appeared online and in newspapers and magazines throughout Virginia, Delaware and Pennsylvania. She lives in Delaware with her husband and their many fur babies.

Source Nationalpainreport.com
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FDA Approves Biologic Drug to Treat Several Forms of Arthritis, Ankylosing Spondylitis and Plaque Psoriasis- Pain News

By Staff People who suffer from Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis and Plaque Psoriasis just got some good news:  A new drug called Erelzi just received FDA approval to help manage and treat these disorders. Erelzi (etanercept-szzs) is administered by injection and is now approved for the treatment of the following conditions: moderate to…

FDA Approves Biologic Drug to Treat Several Forms of Arthritis, Ankylosing Spondylitis and Plaque Psoriasis

By Staff

People who suffer from Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis and Plaque Psoriasis just got some good news:  A new drug called Erelzi just received FDA approval to help manage and treat these disorders.

Erelzi (etanercept-szzs) is administered by injection and is now approved for the treatment of the following conditions:

  • moderate to severe rheumatoid arthritis, either as a standalone therapy or in combination with methotrexate (MTX);
  • moderate to severe polyarticular juvenile idiopathic arthritis in patients ages two and older;
  • active psoriatic arthritis, including use in combination with MTX in psoriatic arthritis patients who do not respond adequately to MTX alone;
  • active ankylosing spondylitis (an arthritis that affects the spine); and
  • chronic moderate to severe plaque psoriasis in adult patients (18 years or older) who are candidates for systemic therapy or phototherapy.

Erelzi (etanercept-szzs) is “biosimilar” to Enbrel (etanercept), which as FDA approved in 1998.  Both are biologic products derived from a living organism.  A biosimilar is a biological product that gains FDA approval based on a showing that it is highly similar to an already-approved biological product and has no clinically meaningful differences in terms of safety and effectiveness from the reference product, in addition to meeting other criteria specified by law.

“The biosimilar pathway is an important mechanism to improve access to treatment for patients with rheumatic and autoimmune diseases,” said Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research. “We carefully evaluate the structural and functional characteristics of these complex molecules. Patients and providers can have confidence that there are no clinically meaningful differences in safety and efficacy from the reference product.”

“We continue to increase patient access to key treatment options by expanding our offering of biosimilars which helps to reduce costs within the healthcare system” said Carol Lynch, global head biopharmaceuticals, Sandoz – the maker of Erelzi.

“Sandoz is proud to have developed two of the three biosimilars that are currently FDA approved, which further demonstrates our commitment to US patients in a growing number of therapeutic areas. We are committed to bringing Erelzi to the US market as soon as possible.”

Source Nationalpainreport.com
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Children and Pain: Acupuncture Provides Pain Relief for Kids with Chronic Conditions- Pain News

By Staff Acupuncture appears to be an effective pain management tool for children who have chronic medical conditions, according to a study published by Gillette Children’s Specialty Healthcare. The study found that a significant portion of children who have chronic care conditions – many of whom are already on numerous medications – might benefit from the…

Children and Pain:  Acupuncture Provides Pain Relief for Kids with Chronic Conditions

By Staff

Acupuncture appears to be an effective pain management tool for children who have chronic medical conditions, according to a study published by Gillette Children’s Specialty Healthcare.

The study found that a significant portion of children who have chronic care conditions – many of whom are already on numerous medications – might benefit from the use of the low-risk and non-toxic benefits of acupuncture. The study, “The Use of Acupuncture in a Pediatric Chronic Care Setting: Clinical Applications” was published in a recent edition of Medical Acupuncture.

Many patients who have complex medical conditions such as cerebral palsy, spinal cord injuries and other brain and musculoskeletal conditions experience chronic pain. As a result, they are often medicated with drugs that can make them sleepy, gain weight and exacerbate mood swings that burden both the child and their families, says Scott Schwantes, M.D., a pediatrician at Gillette Children’s Specialty Healthcare and lead author of the study.

“A lot of these patients have gone through a tremendous amount of physical and emotional pain,” Schwantes says. “These kids have a complex array of distressing symptoms that decrease their quality of life. For some of them, acupuncture may be a valuable tool to add to their treatment.”

This retrospective case series highlights patients referred for acupuncture between June 2014 and June 2015. Fifty two (52) unique patients received 136 acupuncture treatments in the clinic or hospital setting. Patients received treatments based upon their backgrounds and presenting complaints along with energetic work, biomechanical treatment (surface release technique, percutaneous electrical nerve stimulation), and/or auriculotherapy (ear stimulation).

All of the patients received notable benefits from acupuncture – spanning from decreased pain to complete relief.

Acupuncture therapy takes about 30 minutes and involves placing a series of needles at precise points on a patient. The minimally invasive, outpatient procedure could be an alternative for children who are already burdened with surgeries, frequent hospital stays and medications, Schwantes says. The largest drawback to the procedure is needle phobia in some children.

“The proof is with the patients. They’re the ones who are successfully recovering from pain,” Schwantes says. “This study shows that acupuncture can be a safe, well-tolerated, and effective therapy for children and young adults with pediatric-onset disabilities.”

Source Nationalpainreport.com
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A National Campaign Calls for Investment in Pain Research and Access to Pain Therapies- Pain News

By Ed Coghlan The nation’s largest pain patient advocacy group has launched a campaign called “People With Pain Matter”. The U.S. Pain Foundation wants to  raise public awareness of the impact of chronic pain on the lives of nearly 100 million people. Not coincidentally, the announcement comes on the eve of Pain Awareness Month in…

A National Campaign Calls for Investment in Pain Research and Access to Pain Therapies

By Ed Coghlan

The nation’s largest pain patient advocacy group has launched a campaign called “People With Pain Matter”. The U.S. Pain Foundation wants to  raise public awareness of the impact of chronic pain on the lives of nearly 100 million people.

Not coincidentally, the announcement comes on the eve of Pain Awareness Month in September and as the national political campaign begins to move into its final phase.

People with Pain Matter plans to mobilize citizens to take legislative and regulatory actions, influence candidates for public office and members of the media, and leverage social media to encourage policymakers, candidates, and other healthcare stakeholders to enact policies that recognize that people with pain matter. Its website, PeoplewithPainMatter.org, provides a platform for stakeholder education and engagement.

“Just because your pain may be quiet doesn’t mean you have to be,” said Paul Gileno, CEO of the U.S. Pain Foundation. “Together, we must champion pain care improvements in America. Those with pain deserve to be heard and they deserve access to all forms of pain relief.”

One-third of US citizens experience some type of chronic pain. This includes a range of conditions including cancer, Crohn’s disease, rheumatoid arthritis, and traumatic injuries. Yet, people with chronic conditions are increasingly being denied access to pain relief. Labeled as addiction risks, many people with pain have no other options and no access to medical disciplines that reduce pain by treating the whole person.

“It is time to remove the barriers to care caused by destructive public perception and marginalization of people with pain,” Gileno concluded.

U.S. Pain Foundation-which claims 70,000 members and 100,000-plus social media followers points out only 1 percent of the National Institutes of Health’s (NIH) research funding is targeted to pain research.

The campaign will dedicate its efforts to address the urgent needs of people living with pain, combat the stigmatization of people with pain, and call for a national investment in pain research to develop new pain therapies and treatments.

Source Nationalpainreport.com
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Relief for Stroke Survivors with Shoulder Pain- Pain News

By Ed Coghlan Up to 85% of stroke survivors suffer from chronic shoulder pain and that pain often stops them from continuing their efforts to rehabilitate after their stroke. When a stroke survivor can no longer move his or her arm, the muscles will atrophy. The shoulder will essentially separate and the pain from the…

Relief for Stroke Survivors with Shoulder Pain

By Ed Coghlan

Up to 85% of stroke survivors suffer from chronic shoulder pain and that pain often stops them from continuing their efforts to rehabilitate after their stroke.

When a stroke survivor can no longer move his or her arm, the muscles will atrophy. The shoulder will essentially separate and the pain from the shoulder will often cause them to drop out of rehabilitation.

Choices like opioids, short term joint injections and immobilization might help relieve the pain in the short-term but they don’t address the cause—how to settle down the axillary nerve.

Doctors are having some success with a recently FDA cleared device that treats chronic pain of a peripheral nerve origin. In fact, it was the first implantable neuromodulation device cleared for peripheral nerve pain.

The StimRouter was developed by Bioness, a southern California company that was founded by the legendary Al Mann, the entrepreneur and philanthropist who founded companies that focused on cardiac pacemakers, insulin pumps, spinal cord stimulators and cochlear implants.  Mann passed away earlier this year.

“The goal is to get the stroke patient back into rehab,” said Mark Geiger, Global Director of Marketing Implantables for Bioness. “By targeting the pain at its origin, we believe we have an answer for the chronic shoulder pain that plagues stroke survivors.

Bioness_stimrouter_Set3_073015_implant

The StimRouter System
(Click to expand image)

The StimRouter is being marketed as a minimally invasive, long-term treatment option. No batteries are implanted. There’s less lead migration which is a big challenge for more invasive treatments.

Many pain physicians like what they see so far.

“This represents a paradigm shift in the management of post-stroke shoulder pain,” said Dr. Michael Sein, a rehabilitation physician at Weill Cornell Medicine in New York. “I like the ease of implementation which can be completed in an ambulatory setting as well as the significant levels of pain reduction that is achievable in patients that have failed to improve with prior therapy.

According to Dr. Sein, the traditional therapy has included physical therapy, medications and corticosteroid injections.

While the device was approved last year, the Company just launched the product in early 2016 and is still training pain and rehabilitation physicians around the country. Currently about 70 physicians are trained.

“That number is increasing by the month,” said Geiger.

The StimRouter is also approved for treatment of upper or lower limbs, entrapment syndromes, intercostal neuralgias and other peripheral injuries or disease.

Dr. Porter McRoberts of Fort Lauderdale, Florida is an interventional pain physician who has also used the device.

“100% of my implanted patients have had dramatic improvements in pain, said Dr. McRoberts. “One patient has even had complete resolution of her symptoms. I’ve been extremely happy.”

The Company hopes that for physical therapists and occupational therapists, the StimRouter may help these professionals successfully rehab more of the 800,000 Americans who suffer a stroke each year.

Source Nationalpainreport.com
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Opiate Tolerance – FACT OR FICTION- Pain News

By Steve Ariens, Ph.D. We often hear about chronic pain patients need to increase their dosage because of tolerance to their medication(s). Many of the people that put out all these “facts” tend to blend various facts about pain medications – opiates in particular – and apply it to all those who use opiates both…

Opiate Tolerance – FACT OR FICTION

By Steve Ariens, Ph.D.

Steve Ariens

Steve Ariens, PhD

We often hear about chronic pain patients need to increase their dosage because of tolerance to their medication(s).

Many of the people that put out all these “facts” tend to blend various facts about pain medications – opiates in particular – and apply it to all those who use opiates both legally and illegally.

Factually, those people who use opiates illegally – to get high – to silence the demons in their head and/or monkeys on their backs… will rather quickly develop a tolerance to getting “high” off of the same amount of opiates … so they tend to increase the amount of opiates that they take to seek that “high” that they were able to reach when they initially started abusing some substance.

Normally, after a rather short period … one to two years… the substance abuser can no longer get a high from the substance that they have in the past, because of tolerance…but they are forced to continue using the substance because of WITHDRAWAL or what a substance abuser calls “dope sick”.

Now the chronic pain patient, many of whom are under treated in the first place. Their pain is caused by a disease state and all too often disease states tend to deteriorate over time and will cause additional pain.

Additionally, many chronic pain patients start down their pain path while they are in their younger years.. And aging itself will cause more aches and pain on top of the aches and pains they are experiencing from their disease state.

Then there is activity induced pain. Most chronic pain patients only wish to be able to act/function like other people… to be “normal”.  Many circumstances will cause them to not “pace themselves”.. trying to do something, keep up with friends or family at a family gathering, or just try to do personal care issue and tasks around the home.

Some profess that rotating opiates helps prevents a patient’s tolerance, but there is no black/white formula of xx mgs of drug A is equal to xx mgs of drug B. What ends up happening is the patient’s pain management is titrated up on drug B and everyone ends up happy believing that they are addressing “opiate tolerance” for the pt.

A patient’s need for increased dosing, doesn’t need a PhD in Pharmacodynamics, just a little common sense will explain a lot.

Source Nationalpainreport.com
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New Direction for Painkiller Research: Target Opioid Receptors Outside of the Brain to Reduce Side Effects- Pain News

By Staff There may be a new direction in the development of opioid medication after researchers discover a different target for opioid receptors in the brain.  Most opioid pain medications target what is called the mu opioid receptor in the brain, which result in side effects and the potential for abuse.  Researchers found that targeting…

New Direction for Painkiller Research: Target Opioid Receptors Outside of the Brain to Reduce Side Effects

By Staff

There may be a new direction in the development of opioid medication after researchers discover a different target for opioid receptors in the brain.  Most opioid pain medications target what is called the mu opioid receptor in the brain, which result in side effects and the potential for abuse.  Researchers found that targeting delta opioid receptors on sensory neurons in peripheral tissues can avoid the side effects and abuse potential with current opioid pain medications.

“People living with chronic pain have few innovative analgesic options available to them outside of systemic opioids,” says senior study author Nathaniel Jeske of the University of Texas Health Science Center at San Antonio. “Being able to increase the responsiveness of peripheral opioid receptor systems could lead to a reduction in systemic opioid administration, thereby reducing the incidence of side effects.”

The study in rats, which was published August 25 in Cell Reports, set out to address the problem of mu opioid receptors by targeting delta opioid receptors in the peripheral nervous system rather than the brain and spinal cord, which could produce fewer side effects in animals.

Jeske and lead author Allison Doyle Brackley, also of the University of Texas Health Science Center at San Antonio found that a protein called GRK2 binds to and prevents delta opioid receptors on rat sensory neurons from responding normally to opioids.  When these peripheral neurons were exposed to a natural inflammatory molecule called bradykinin, GRK2 moved away from the delta opioid receptors, setting off a biochemical reaction that restored the functioning of these receptors.

So, the rats with the reduced GRK2 levels regained their sensitivity to the pain-relieving effects of the drug that activates the delta opioid receptors – and did so without the need for an inflammatory trigger.

“By shedding light on how inflammation activates delta opioid receptors, this research could potentially lead to the development of safer, more effective opioids for the treatment of pain,” Jeske said.

The researchers’ next steps are to attempt to replicate the findings in rats, using human tissue.

Source Nationalpainreport.com
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DEA Moves on Kratom Classification- Pain News

by Ed Coghlan The Drug Enforcement Administration (DEA) is continuing to try and squeeze what it believes are addictive drugs and properties.  Today it announced its intention to place the active materials in the kratom plant into Schedule I of the Controlled Substances Act in order to avoid what it calls “an imminent hazard to…

DEA Moves on Kratom Classification

by Ed Coghlan

The Drug Enforcement Administration (DEA) is continuing to try and squeeze what it believes are addictive drugs and properties.  Today it announced its intention to place the active materials in the kratom plant into Schedule I of the Controlled Substances Act in order to avoid what it calls “an imminent hazard to public safety”.

Kratom is a relatively new drug to the US and Europe.  It has been used for many years in Southeast Asia as an anti-diarrheal medicine, a painkiller and a recreational drug.

It has been reaching the United States in larger proportions. The DEA says over 55,000 kilograms were “encountered” by law enforcement between February 2014 and July 2016.  Law enforcement nationwide has seized more kratom in the first half of 2016 than any previous year and easily accounts for millions of dosages intended for the recreational market, according to DEA findings

Kratom is abused for its ability to produce opioid-like effects and is often marketed as a legal alternative to controlled substances.  In addition, kratom has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and has a lack of accepted safety for use under medical supervision.  These three factors constitute a Schedule I controlled substance according to the Controlled Substances Act passed by Congress in 1970.

Kratom has been seized by law enforcement in various forms, including powder, plant, capsules, tablets, liquids, gum/resin, and drug patch. Because the identity, purity levels, and quantity of these substances are uncertain and inconsistent, they pose significant adverse health risks to users.

The FDA has also warned the public not to use any products labeled as containing kratom due to concerns about toxicity and potential health impacts. In addition, FDA has issued and updated two import alerts related to kratom products.  Kratom has been on DEA’s list of drugs and chemicals of concern for several years.

The American Association of Poison Control Centers identified two exposures to kratom from 2000 and 2005.  Between 2010 and 2015, U.S. poison centers received 660 calls related to kratom exposure.  The Center for Disease Control (CDC) found that kratom abuse leads to agitation, irritability, tachycardia,  nausea, drowsiness, and hypertension.  Health risks found in kratom abusers include hepatotoxicity, psychosis, seizure, weight loss, insomnia, tachycardia, vomiting, poor concentration, hallucinations, and death.  DEA is aware of 15 kratom-related deaths between 2104 and 2016.

Source Nationalpainreport.com