Emma Yasinski

A recent study showed that both real and sham acupuncture resulted in decreased reports of pain when the patients believed it would work, as well as different brain regions were activated during real versus sham treatment.

Most importantly, the study participants were osteoarthritis patients — patients who were actually dealing with chronic pain.

The trial used real and sham acupuncture coupled with functional magnetic resonance imaging (fMRI) scans to explore the effects of a patient’s expectation that a treatment will alleviate their pain on that treatment’s efficacy.

Randy Gollub, MD, PhD, an associate professor of psychiatry at Harvard Medical School, and her team have done these types of experiments before, but only ever on healthy patients—which may have hidden details.

Some studies, such as a recent one from the University of Michigan, have suggested that chronic pain patients have structural differences in the areas of the brain that are activated during pain modulation, and they may respond to endogenous opioids differently than healthy people do.

“Having the experience of living many, many years with pain may make you think about that differently,” Gollub told 

. “So, we took a study and we replicated it in a population and then we asked the question, ‘What does this look like in the brain?’”

The study included 42 patients, all suffering from chronic pain due to osteoarthritis. The investigators conditioned the patients using the same protocols they had used in previous studies on healthy patients. They told the patients that they would receive 2 identical heat pain stimuli on each of their forearms. On 1 side, they were told they’d receive a treatment to reduce the pain after the first heat pain stimulus.

In reality, on the “treated” forearm, the second stimulus was a lower temperature than the first. On the untreated side, they received identical stimuli. This enhanced the feeling of analgesia, helping to convince the patients that the treatment was effective.

Each patient participated in 2 behavioral testing sessions which included neuropsychological assessments, and 1 fMRI scanning session. Each session was separated by 3 to 10 days.

The researchers found that behaviorally, both healthy patients in previous studies and chronic pain patients in the current study responded the same way to treatment. Most reported decreased pain for both real and sham acupuncture.

Interestingly, the brain scans showed slight differences in the areas that were processing these sensations.

Gollub explained that this study only included osteoarthritis patients and that she compared their data to previous studies on healthy patients, so future studies will need to include healthy, matched controls.

“That the time that [doctors] spend and the relationship that they build with [their patients], and the expectation that they create, that they're there to help their patient feel less pain and be more comfortable, is an important ingredient in their therapeutic armamentarium,” Gollub said. “We can tell from people's brain scans that their belief in the treatment has an impact on how they experience pain.”

The study, “A Functional neuroimaging study of expectancy effects on pain response in patients with knee osteoarthritis,” was published in the 

This article was originally published by 

Articles

Chronic pain patient may respond to endogenous opioids differently than healthy people.

Belief in Treatment Can Affect Patient Response to Pain Therapy

Migraine patients suffer more than nearly all other chronic pain patients according to a new study from what may be considered an unlikely place—plastic surgeons at Harvard Medical School.

In 2000, Bahman Guyuron, MD, a plastic surgeon in Cleveland, Ohio, performed forehead restoration surgery on a patient. Later, that patient reported that she’d stopped experiencing migraines. Building on this observation, Guyuron hypothesized that migraine pain could be caused by nerves trapped between muscles, bones, and fascia.

Since then, he and other plastic surgeons, including Lisa Gfrerer, MD, PhD, a resident at Harvard Plastic and Reconstructive Surgery in Boston, Massachusetts, have been providing surgery to migraine patients who have exhausted other treatment options.

For years, doctors have used a standard migraine scale to assess patients’ pain. They use a migraine-specific scale to judge how much a patient improves after different types of treatment ranging from medications to botox injections. But lead author Gfrerer wondered if these scales were sufficiently gauging her surgery patients’ experiences.

“What we really wanted to look is at how their function improves because we feel like that is the most important thing for patients. It's not whether they have a headache 20 times a month or 50 times a month,” she said. “It's about how can they function in their daily lives?”

She and her team gave patients both the standard migraine questionnaires and the Pain Self Efficacy Questionnaire (PSEQ,) a questionnaire designed to measure function in other types of pain patients, to measure how their pain impacted their daily lives.

The team found that before surgery, migraine patients struggled to function more than any other type of pain patient. “They're really in tremendous pain,” Gfrerer said. “They really can’t do a lot because they're so disabled by their migraine.”

After completing both questionnaires, 90 patients underwent migraine surgery at Massachusetts General Hospital and were assessed again a year later. The mean PSEQ score was 18.2 ± 11.7.

According to the study, the patients who underwent surgery improved in their daily functioning by an average of 112% (P <.01). “That’s huge,” Gfrerer said.

Using surgery as a treatment for migraines is still controversial. Some neurologists would never have their patients with migraines screened for surgery. But Gfrerer says that over the past few years that’s started to change, thanks to increased evidence for extracranial sources of migraine.

  Marc Lenaerts, MD, FAHS, an associate professor of clinical neurology at the University of California at Davis, who also researches migraines but was not involved in the study, is not quite convinced. He wants to see more research, ideally, a randomized study with controls.

Nonetheless, both researchers agree that the study’s biggest takeaway is the measurement of just how much pain migraine patients are experiencing.

“Your brain is intact and so you may feel that people [with migraines] should be functioning better because there's no structural damage,” Lenaerts said. “[The study] highlights a tool that may, in the future, bring more awareness and more insight into the functional disability of migraine nerves.”

Lenaerts added that he’d like to see more studies conducted with the PSEQ.

The study, “Ability to Cope with Pain Puts Migraine Patients in Perspective,” was published in 

Migraine pain may be caused by nerves trapped between muscles, bones, and fascia, which could be reduced by forehead restoration surgery.
 