Fighting pain

By Usha Perera
“I had observed that chronic pain is not managed well in Sri Lanka and it is for this reason that we thought that we should open a separate pain management centre,” says Dr Namal Senesinghe, a consultant in Pain Medicine at Canterbury Hospital in Kent, UK.
Dr Senesinghe after graduating from North Colombo Medical College in Sri Lanka, left for the UK about 16 years ago for further studies and specialized in pain management in the UK.
He is also the director of Kent Pain Services LTD, UK.

“During my trips to Sri Lanka through the years I met so many friends and family members who were suffering from chronic pain due to various problems but there was no proper centre where they could go for treatment. Even though the need to open a pain management centre was foremost in my mind for several year, I did not have the correct partnership until now,” says Dr Senesinghe.
He says grateful for Professor Arjuna de Silva for facilitating a dialogue with Nawaloka hospitals.
A state-of-the-art medical centre aimed at pain management was launched at Nawaloka hospital; Colombo on December 30, 2010.
This centre will bring together both local and foreign expertise enabling treatment of various diseases, which cause pain.

Diseases such as back pain, neck pain, and joint pains of knees, shoulders, hands and feet will be treated along with various diseases causing pain in other areas of the body.
“Generally pain is divided into two groups, acute and chronic. Acute pain is generally post operative pain and pain that last for less than three months, but chronic pain is pain that lasts for more than three months. Chronic pain can be further divided into nociceptive pain and neuropathic pain. Nociceptive pain does not have neurological involvement and the commonest of this type is back pain. About 80 – 90% of patients that I see in England are those with back pain,” explains Dr Senesinghe.
“Neuropathic pain occurs due to altered sensations of the autonomic nervous system and encompasses the neuralgias such as trigeminal neuralgia, phantom limb pain that is experienced by people who lose their limbs, post orbital pain, scar pain etc,” he further explains.
Regarding the concept of pain management, Dr Senesinghe says that currently throughout various parts of the pain it is considered a sub specialty, but that due to its importance it might develop into a specialty in the near future.

“Currently it is well established in the US and UK, and developing in Australia. In this part of the world in South East Asia, it has just started to develop. The importance of this is not merely for the individual but also causes a huge economic burden to the countries. Currently it is estimated that United Kingdom spends 700 million sterling pounds yearly to treat chronic pain and similarly US spends four billion dollars a year. Therefore the target is to identify those patients with chronic pain as early as possible and then manage the pain so that they would be able to lead as normal lives as possible,” he further explains.
The pain management centre opened at Nawaloka hospital will function almost seven days a week says Dr Senesinghe. Dr Tharindu Wijesinghe, consultant rheumatologist who has trained in Australia will be seeing patients on a day to day basis, while Dr Senesinghe says that he will be visiting Sri Lanka about four times an year.

“Dr Wijesinghe will treat all patients who will come to the clinic and then any other patients who he would feel should be best seen by me, would be stacked for my referral,” reiterated Dr Senesinghe.
“This centre will operate on the same principal as the UK pain management unit. The minimum time taken to see a patient will be fifteen minutes and we will do a stepwise management. First we will see if we can manage them with drugs and if not we will go in for the procedures. But prior to doing the procedure we will inform the patient of all the costs involved in carrying out the procedures,” says Dr Senesinghe.
According to him back pain is the commonest cause of chronic pain. It could be due to a muscular problem, ligamental problem, bony issue, end plate problem, disc prolepses etc. According to the problem, the management procedures will be done. Treatment will include interventions ranging from x-ray guided facet joint injections, nerve root blocks, pulse radiofrequency of nerves, discography, Intradiscal electro thermal ablation, radiofrequency ablation of nerves and state of the art spinal cord stimulators.
“The aim of all these procedures is to give the best possible treatment for the problem. and to make the patient pain free even if it is for a while and that will make them seek pain free physiotherapy which will further support in breaking a vicious cycle,” says Dr. Senesinghe.

“We will also refer the patient for other treatments such as, aromotherapy, water therapy, reflexology etc. We will develop collaborations with other such treatment methods so that we could offer a comprehensive and holistic treatment schedule to our patients,” says Dr Senesinghe.
As a pain management consultant, Dr Senesinghe carries out such procedures in his clinic.
He says that last year alone – in 2010 he carried out 3,200 procedures in pain management.
He says that anything that is available in America and England regarding pain management will be made available here.

Also procedures will be done only if there is adequate evidence.
“For an example it will not be the case of an epidural injection just for the case of a backache. If we do such procedures we will make sure that it is backed by evidence such as an MRI scan and when we do it we will it will be done under x ray guidance and an image intensifier. We will give a copy of the images of the procedures being done to the patient as well. “Without proper evidence doing such procedures will be considered as being overdone.

On a personal note Dr Senesinghe says that he and his wife Ruvini – a consultant psychiatrist in the UK have not shed the emotional bonds with his homeland Sri Lanka even though they currently live in England.
“Our parents live here and we have such wonderful and good friends here and I am so very happy that I was able to do something like this in my own country,” he says.


Treating lower back pain

If you have lower back pain, you are not alone.
Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation.
Back pain is the second most common neurological ailment in neurological clinic, only headache is more common.
Fortunately, most occurrences of low back pain go away within a few days.
Others take much longer to resolve or lead to more serious conditions.
Acute or short-term low back pain generally lasts from a few days to a few weeks.
Most acute back pain is mechanical in nature, the result of trauma to the lower back or a disorder such as arthritis.

Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues.
Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight.
Occasionally, pain felt in one part of the body may ‘radiate’ from a disorder or injury elsewhere in the body.
Some acute pain syndromes can become more serious if left untreated.
Chronic back pain is measured by duration — pain that persists for more than three months is considered chronic.

It is often progressive and the cause can be difficult to determine.
The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis.
The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord, the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations.
Stacked on top of one another are more than 30 bones, the vertebrae that form the spinal column, also known as the spine.

Each of these bones contains a round hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord.
The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage.
Small nerves enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting.
This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail.
The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves.
Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.
Starting at the top, the spine has four regions:
• the seven cervical or neck vertebrae (labeled C1–C7),
• the 12 thoracic or upper back vertebrae (labeled T1–T12),
• the five lumbar vertebrae (labeled L1–L5), which we know as the lower back, and
• the sacrum and coccyx, a group of bones fused together at the base of the spine.
The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.

Causes of lower back pain
As people age, bone strength and muscle elasticity and tone tend to decrease.
The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.
Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward.

This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain.
When these nerve roots become compressed or irritated, back pain results.
Low back pain may reflect nerve or muscle irritation or bone lesions.
Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine.
Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain.
Occasionally, low back pain may indicate a more serious medical problem.
Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition.

People most likely to develop low back pain
Nearly everyone has low back pain sometime. Men and women are equally affected.
It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary life styles with too little exercise.
The risk of experiencing low back pain from disc disease or spinal degeneration increases with age.
Low back pain unrelated to injury or other known cause is unusual in pre-teen children. However, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. Recently a study was done in Sri Lanka to find out the strain of heavy backpacks on children.
To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, and should minimise the load they are carrying.


Stop, rewind: Slowing the ageing process

Scientists are slowly unlocking the secrets of ageing, and some suggest treatments may soon be at hand to slow or even reverse the ageing process.
But what can science really achieve, and what are the dangers of meddling with our biological clocks?
Could such treatments induce cancers in humans, for example, and what about the world’s burgeoning population and the West’s “pension time bomb”?
The ageing process is a complex one, and for long remained an impenetrable mystery, but progress is now being made.

Late last year, a team at the Dana-Farber Cancer Institute in Boston published a Nature paper in which they detailed the reversing of the ageing process in mice.
They targeted the chromosomes that reside within the nuclei of all cells, and specifically telomeres, caps at the tips of chromosomes. The telomeres protect the chromosomes from damage, but also shorten with age, until the cells are no longer able to replicate.

Professor Ronald DePinho and colleagues manipulated the enzyme that regulates these tips – known as telomerase – and witnessed dramatic results. Boost the enzyme, and the mice appeared to rewind the clock.
“What we were expecting was a slowing or stabilisation of the ageing process,” he told the BBC. “Instead we witnessed a dramatic reversal in the signs and symptoms of ageing.”
“These animals had their brains increase in size, they improved their cognition, their coat-hair was restored to a healthy sheen and their fertility was also restored.”
Of course, this was a story of mice, not men, and applying such principles to humans could be an altogether bigger challenge. Telomerase has been linked with cancer, and there are likely to be many other mechanisms involved in ageing.

Many believe mitochondria may play a bigger role – genetic material contained within the cell but outside the nucleus. Mitochondria are the “power houses” of cells, but have also been seen to generate harmful chemicals linked with aging.
Then there is the role played by free radicals, highly reactive atoms or molecules that attack our bodies. Stem cells, primitive cells which play a key role in renewing the human body, are also likely to be involved.
But even though a comprehensive picture of how we age is still to be constructed, there are scientists who are already testing anti-ageing treatments on humans.
Professor David Sinclair also works in Boston at an ageing laboratory at Harvard Medical School. He and his colleagues have been working on synthetic drugs called “Sirtuin activating compounds” or STACs.
Animal studies have indicated STACs can restore the health and life prospects of obese mice and early-stage trials in humans are now underway.

The research follows earlier work on resveratrol, a naturally-occurring ingredient of red wine. Both resveratrol and STACs appear to mimic the effects of restricting calorie intake, which has been seen to slow ageing in animals.
“This isn’t going to be an excuse to eat French fries all day and watch TV but is a way to augment your healthy lifestyle and give you the ultimate benefits of perfect health which your body is capable of,” Professor Sinclair told the BBC.
(BBC Health)


Blocking a gene stops cancer cells spreading

A gene which encourages cancer to move around the body has been discovered by the University of East Anglia.
Experiments on tissue cultures, published in Oncogene, suggest that blocking it would prevent cancers spreading.
The researchers hope their work will lead to a new generation of cancer drugs within the decade.
Cancer Research UK said the study improved understanding of the disease, but was still at the laboratory stage.
There are treatments for primary cancers, but tumours have the potential to spread.
Cells can break off and travel around the body, through the bloodstream or lymph fluid, and start a new or secondary tumour where they land, a process known as metastasis.

Breast cancers are known to spread to lymph nodes, the bones and the lungs.
These secondary tumours are notoriously difficult to treat.
The team at the University of East Anglia has found a gene which helps the cancer spread.
The gene, WWP2, leads to the breakdown of an inhibitor that normally keeps cells in check.
The researchers showed, in tissue cultures, that without the inhibitor, Smad7, cancer progressed very quickly and spread.

Blocking the gene prevented that spread.
Dr Andrew Chantry, who led the study, said: “I think we’re really onto something important if we can put a wall around a cancer and lock it in place.
“The discovery could lead to the development of a new generation of drugs within the decade that could be used to stop the aggressive spread of most forms of the disease.”
The team are now recruiting chemists to help them design a drug which could interrupt the gene’s activity.
Dr Kat Arney, science information manager at Cancer Research UK, said: “Over recent decades researchers all over the world have discovered genes that drive the growth and spread of cancer, and this research adds one more to this ever-growing list.
“But, while these new results aid our understanding of the complexities of cancer and could point towards potential leads for future anti-cancer drugs, the work is still at the laboratory stage.”

(BBC Health)