Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders, according to a new study by University of Washington researchers published in the latest issue of journal Pain. This study examined the role of fear after whiplash and assessed the effectiveness of 3 treatments targeting fear. They evaluated 191 people still suffering from whiplash symptoms 3 months after the injury. Patients were assigned to one of the following three treatments: (1) informational booklet describing whiplash disorder and the importance of resuming activities, (2) informational booklet plus a discussions with clinicians reinforcing the booklet, and (3) informational booklet, plus a psychological technique called imaginal and direct exposure desensitization to feared activities. The second and the third group received three 2-hour treatment sessions. Those given psychological intervention reported significantly less post-treatment pain severity compared with those given a brochure or brochure and discussion. Reduction in fear was the most important predictor of improvement, followed by reductions in pain and depression. The authors concluded that the results highlight the importance of fear in individuals with persistent whiplash injury symptoms and suggest the importance of addressing fear through exposure therapy and educational interventions to improve function.

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Botox seems to help neck and upper back muscle pains, according to a recent study by UCLA doctors. We know that one of the actions of Botox is to relax muscles and it has been effective for the treatment of sciatic pain, according to a previous blinded study. Drs. Nicol and Ferrante at UCLA gave a single injection of Botox to 118 patients with neck and upper back pain. Six weeks later 54% of patients showed improvement. Then, 8 weeks later, half of the 54 responders were given again Botox and the other half placebo (saline injection). Those who received Botox did much better not only on pain scores, but also on quality of life measures. They also had a significant improvement in the number of headaches. This is not that surprising, since many of our patients report that their headaches begin with muscle spasm in the neck or upper back. It is very likely that giving more than one injection will lead to a greater improvement in a larger percentage of patients. In chronic migraine headache patients injecting Botox into 31 sites has been proven to be very effective.

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The importance of context: When relative relief renders pain pleasant, is the title of an article recently published in the leading international medical journal, Pain. British and Norwegian researchers examined how context can influence the experience of any event. For instance, the thought that “it could be worse” can improve feelings towards a present misfortune. They measured hedonic (pleasant) feelings, brain activation patterns, and skin conductance (which indicates stress, since increased sweating increases electrical skin conductance; this phenomenon is also used in biofeedback). 16 healthy volunteers experienced moderate pain in two different contexts. In the “relative relief context,” moderate pain represented the best outcome, since the alternative outcome was intense pain. However, in the control context, moderate pain represented the worst outcome and elicited negative hedonic feelings. The context manipulation resulted in a “hedonic flip,” such that moderate pain elicited positive hedonics in the relative relief context. Somewhat surprisingly, moderate pain was even rated as pleasant in this context, despite being reported as painful in the control context. This “hedonic flip” was confirmed by skin conductance and brain activation patterns on MRI scans. When moderate pain was perceived as pleasant, skin conductance and activity in certain parts of the brain were significantly reduced, relative to the control moderate stimulus. “Pleasant pain” also increased activity in reward and pain relieving brain centers. The context manipulation also significantly increased connections between reward circuitry and the pain relieving centers.

Photo credit: JulieMauskop.com

Burning mouth syndrome (BMS) affects over a million Americans. It has no known cause or otherwise it would not be called a syndrome. For example, burning pain in the mouth due to chemotherapy damage to the mouth lining is called oral mucositis. This condition is not related to migraines, but just like with migraines, three times as many women suffer from BMS than men. Some people with BMS have a sensation of having sand in their mouth and itching, in addition to the burning pain. The pain can be very intense and can persist for many months. A recent study by Italian researchers published in the journal Headache examined 53 patients with with BMS and compared them to 51 healthy volunteers. They discovered that patients with BMS were much more likely to have anxiety and depression than the healthy controls. This is not surprising since patients with chronic headaches or pain of any kind are also more likely to be anxious and depressed. This does not mean that the pain is a manifestation of depression, as suggested by the authors.
A more interesting study of BMS in the same issue of Headache was published by Brazilian doctors. They treated 26 patients with mechanical stimulation of their mouth in order to increase the flow of saliva. This was achieved by having patients chew on a rubbery stick for ten minutes three times a day for 90 days. This resulted in a significant reduction of pain, even though the amount of saliva produced did not increase. In addition to improvement in pain, they also had fewer burning sites in the mouth and their taste improved as well.
Another approached that has been used to increase the flow of saliva reported in the medical literature is to stimulate salivary gland with a transcutaneous electrical nerve stimulation (TENS). The TENS electrodes are applied to the skin over the parotid salivary glands. There has been no reports of using TENS for the treatment of BMS, but considering that it is a safe and inexpensive treatment, it may be worth a try.