Cold feet is a term used to characterize apprehension or doubt strong enough to prevent a planned course of action. It is also a British comedy drama television series produced by Granada Television for the ITV network. But, for those of us who survived polio, and that means virtually everyone who is reading this, cold feet has a very different meaning. It is something that has interested me ever since I first contracted polio. Why, I wondered, was my left foot so very cold, and why was it that quite unattractive shade of blue?

When I asked my Doctor, he merely shrugged his shoulders and said something about lack of movement and poor blood circulation in the foot. Thatwasn't good enough for me. I was looking for much more detail. So I decided (at 10 years of age!) to examine the cause further, and find a medical explanation for it.

One theory says thatmuscles that don't work don't bring warm blood to the foot because the muscles don't work. Another says that the virus attacked the motor neurons and sensory nerves.(Huh???) So the veins become too open, and the blood supply forms a "pool" in our feet - and that is what gives our feet that attractive(?) bluish purple color as well as making them as cold as they are.

Strangely enough, some people who didn't get polio also have cold feet - but us "Polios" get cold feet even in a warm room.

Right.... so now that we know why our feet get so cold - or think we know why - what can we do about it? Surprisingly, there is quite a lot that we can do. Read Linda Wheeler Donahue's article which follows, for some very good advice........

And what about pain? That's something that all of us PPSers know intimately. What exactly is pain? .....and what can we do about it? Do we just have to grit our teeth, swallow a pill -and put up with the pain? Later in this publication, there are two articles on the subject of pain, One is a fairly short article, (an excerpt from the Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors) and the other is an extensive article on pain - what it is, why it is, what (little) we can do about it and so on. It is rather a long piece, which I had thought as first, about serializing over two or three issues, but because all of us are so very familiar with, and racked with pain, I thought that it might be better to read it all at once.

We have recently held elections within IPPSO and the following persons have been elected to the positions indicated:-

I want to thank all those members that participated in the recent IPPSO elections. I look forward to trying to fulfill the role of President in the same spirit as my predecessor, Shari Fiksdal, who is still having a painful recovery from her rotator cuff surgery. Only with the assistance of Shari, the rest of our Board of Directors and volunteers will we be able to move forward to successfully support our members through this Magazine, our Yahoo group bulletin boards, chats, and private emails; as well as comply with the legal aspects and keep up with the administrative duties of our organization. Another very important component to our success is the willingness of our members to actively participate by writing articles for our magazine and participating at our bulletin board and in our chats.

One of our main goals for 2009 is to get a grass-roots effort started to educate our Congressmen and testify before Congress in order to get more monies funded for research that would benefit polio survivors. Right now, we think that getting a biomarker documented that would prove that a person had polio or Post Polio Syndrome as well as research to get FDA approval for the use of IV gamma globulin as needed for a person with PPS is our most important goals. We would also appreciate our members input as to what you think are the unmet needs in our PPS community. IPPSO will also support these efforts on a global level through communications in our Yahoo group bulletin board and chat for Polio-World which is a forum for PPS group leaders around the world.

I just arrived in Warm Springs, Georgia and have a few days to rest up before attending Post Polio Health International’s 10^th International Post Polio Conference. I hope to gain a lot of new members that will actively join our grass-roots efforts and will be reporting back to you on what else was learned. Our IPPSO 2^nd Vice President, Susan Kerr, will be here at Warm Springs too as a representative of her New Zealand Polio Society and our Director of Public Relations, Elizabeth Lounsbury, is here representing her Polio Canada. I am also representing my Miami, Florida Post Polio Group who has assisted me by paying my conference registration fee.

VERY IMPORTANT! For those that have tried to pay their membership dues or make a contribution by a check that has not yet been cashed or been unsuccessful in using Paypal on our ippso-world.org website, please accept our apologies. We had some unfortunate “glitches” that we are just getting a handle on and all should be taken care of shortly. Please do consider donating to us as you are able in the future though. We have only about $500 in our Treasury and that needs to be reserved to pay our web site domain fees and our web-hosting fees. As we have mentioned before, our Board of Directors are all on fixed incomes and spending our own monies limits our activities for the good of the organization. We will be glad to email anyone our financial statements. A designation can be made for a donation to be restricted to be spent for a specific purpose. We still hope to get a program for a bulletin board and chat set up on our web site which would be much easier to use than Yahoo Messenger, but that costs us an initial set-up fee and then a monthly fee.

I look forward to hearing from or visiting with all of you. You can email me at ppsofsouthfl@aol.com. Warm Regards to all

Barbara Gratzke

Hehehe Corner

If you really want to know the truth, most useless PPS Doctors are alive only because it is illegal to shoot them.

Cold Intolerance: Part 1

After a long career of teaching college English, literature, speech, and humanities, Professor Linda Wheeler Donahue took disability retirement after attaining the title of Professor Emeritus. She now spends her time researching and writing on matters of interest to polio survivors (while snugly bundled up in layers of warm clothing!)

An energetic speaker, Linda has presented at numerous disability conferences and seminars across the country. She is President of The Polio Outreach of Connecticut and welcomes feedback at LinOnnLine@aol.com. You can visit her support group at http://www.the-polio-outreach-of-ct.com/

Cold intolerance is one of the more bothersome physical discomforts associated with post-polio syndrome. Why do we feel cold more than people who did not have polio do? This may be a question you have wondered about. I would like to share what some leading polio authorities tell us about why we have the difficulty of cold intolerance. Then I would like to explore some practical suggestions to help you obviate this problem.

Fortunately, the major polio physicians and researchers are quite consistent in their appraisal of this issue. Let’s take a look at what they have to say.

Dr. Julie K. Silver, Director of the International Rehabilitation Center for Polio in Framingham, Massachusetts, explains that polio survivors’ sensitivity to cold is due to atrophied muscles that do not contract adequately, and are therefore unable to assist blood vessels in bringing warming blood to the extremities.

Dr. Richard R. Owen, Emeritus Medical Director of the Sister Kinney Institute, is one of the first experts to describe “polio feet”; in fact, he coined that phrase. People who had polio often have blue, red, or violet feet. Part of the explanation for our colorful tootsies is that the poliovirus not only attacked our motor neurons, resulting in paralysis of our muscles, but also attacked sympathetic nervous system neurons within the spinal cord. When it did that, we lost our ability to control the blood flow into our veins and arteries. When our veins are unable to contract, they become too open. Blood then “pools” in the feet, giving the skin a bluish tint and causing puffy swelling. Our “polio feet” get colder than the feet of someone who did not have polio, since our sympathetic neurons are damaged.

At the time of the original infection, the poliovirus damaged the sympathetic nerves, explains Dr. Lauro S. Halstead, pre-eminent polio author and director of the post-polio program at National Rehabilitation Hospital in Washington, DC. These nerves were part of the autonomic nervous system and their damage caused malfunctioning of the sympathetic nerves.

Dr. Richard Bruno, clinical psychophysiologist, noticed that the skin on the affected arm of his first polio patient was cold to the touch. This suggested a problem of blood flow to the limb. As Dr. Bruno studied more patients, he discovered the same thing. He deduced that the size of the polio survivor’s skin blood vessels could not be regulated properly because the poliovirus killed off the sympathetic neurons in the spinal cord. These are the ones responsible for making the muscles around blood vessels contract.

People who did not have polio may also experience coldness, but Dr. Silver explains that we polio survivors feel this unpleasant sensation even indoors in a warm room. This sets us apart from others. We are often cold even at room temperature because those peripheral nerves that supply the muscles surrounding our blood vessels were damaged when we contracted polio. So when our muscle is cooled, already weakened neuromuscular transmission is made even worse. An added problem is decreased muscle performance in cold temperatures. Some polio survivors report they have increased trouble walking in the cold winter months.

What can we do to keep warm? Our polio experts all agree on this. The management of cold intolerance is largely symptomatic, that is, all we can do is treat the symptoms. There is no known cure.

How do we treat the symptoms? There are a number of easy lifestyle adjustments you can make. One of the most important things you can do is to stay warm from the moment you wake up in the morning. Your body will be warm and snug at that time of the day. So hold on to your body heat with warm socks and layers of clothing. Three thin layers will keep you warmer than one thick layer.

Go to a camping store and purchase clothing made of polypropylene. Polypropylene is comprised of a thin plastic film woven into a soft fiber and is excellent at insulating your skin from the cold. Outdoorsmen have known of its warming properties for years. It is sold under various brand names such as Thinsulate and Gore-Tex.

Skiers and outdoor enthusiasts use a resourceful clothing technique called layering. This is an efficient way to stay warm and comfortable in cold weather by protecting and preserving your core body temperature. One of the advantages of layering is that you can add or remove clothing to adjust to changing conditions.

Here is how layering works. The first layer is the thermal base layer. The fabrics used for this layer are generally stretch knits, often made of synthetic fibers. They are typically lightweight, machine washable, and fast drying. Special occasions sometimes present a warmth-dilemma for women. I recommend silk as a first layer. Silk is non-bulky with a luxurious feel and impressive thermal properties. It is light enough to be undetectable beneath blouses or slacks, yet insulating enough to provide that extra layer of warmth. With a thin silk layer worn as an undershirt, ladies will look trim even in evening clothes. Fancy dress situations no longer have to mean women are freezing!

The second layer is called the mid layer. This is a thicker, cozy layer that really locks warmth in next to your body. Fleece, in various thicknesses, is an excellent mid layer insulator. My favorites are Polarfleece 100 and Polarfleece 200. This space age fabric brings comforting warmth, softness, and lightness. The characteristics of warmth and lightweight are particularly important to polio survivors. We need warmth yet our bodies cannot tolerate dragging around excess weight in the form of heavy clothing. Polarfleece offers a dynamic warmth-to-weight ratio, compared to traditional fabrics. Its tiny springy fibers create multiple air cells to trap warmth inside. This feature provides excellent protection from the cold. Since it does not retain moisture and facilitates evaporation, the fabric remains dry and comfortable. If there is no Polarfleece in your closet, I suggest you head out on a shopping trip. You can shop either in a brick and mortar building or in cyberspace.

The third layer is referred to as the shell layer. This layer must be breathable for the layering system to function. If it is not breathable, condensation will form causing chilling. The top layer, or shell, is often windproof and waterproof. It should be loose fitting to allow for movement. Polarfleece 300 as your third layer will keep you warm no matter what Mother Nature delivers.

It is wise to even layer your socks. Sock liners made of polypropylene are superior heat retainers. They are designed to be worn as a base layer under athletic socks. You may want to try battery operated heated socks. I did not have luck with them as they had uncomfortable seams and hot spots, but they may work for you.

Remember, your entire body must be insulated in order to stay warm, especially in bitterly cold weather. So do not neglect your neck region. Wear a turtleneck style top to warm that area. In addition, do include a hat, mittens or gloves, warm socks, and a scarf when you venture out of doors.

At the GINI Conference in June of 2000, I purchased a fantastic product from one of the many vendors there. These were grain-filled, heat-activated booties. You place them in the microwave for 3 minutes, then put them on and savor the rejuvenating deep heat for over an hour of warmth. I have since seen these in various home health mail order catalogs.

Many of us PPSers spend most of our time indoors, but we still have trouble staying warm. I suggest that throughout the day you take several breaks from your daily activities. Sit in your favorite chair or recliner with your feet elevated as high as possible. I have an old twin size electric heating blanket draped on my recliner ready to warm me up like nothing else. If you do not need that large a covering, try using a warm heating pad and a cozy lap blanket as you rest and enjoy the feeling of your extremities warming up to a comfortable temperature. When your muscles are warm, you not only feel better, but you also move and function with more ease and efficiency.

Many of us suffer with the uncomfortable sensation of feeling cold. The foremost polio physicians offer a clear explanation for why this happens. The good news is that we can make lifestyle changes to remediate this troubling post-polio problem.

Halstead, M.D., Lauro S. Managing Post-Polio: A Guide to Living Well with Post-Polio Syndrome. Arlington, VA: ABI Professional Publications, 1998.

Munsat, Theodore L. Post Polio Syndrome. City: Butterworth-Heinemann Medical Publishers, 1991.

Silver, M.D., Julie K. Post-Polio: A Guide for Polio Survivors and Their Families. New Haven: Yale University Press, 2001.

Life is a waste of time and time is a waste of life, so waste your time and have the time of your life !

I asked twenty-nine polio survivors to share their solutions for warming up those icy cold feet. Here are their responses. I hope some of these tips work for you.

I use electric heating pads over my knees and at my back when sleeping or in my recliner. If I get chilled, it takes me many hours to warm up again.

Hot baths work for me. After my bath, I put on warm hunter’s socks and jump into bed.

I use several layers of flannel blankets and wear long-sleeved pajamas and heavy socks to bed. My side of the bed also has an electric throw.

In winter I wear long-sleeved, lightweight undershirts called "Cuddleduds" under long-sleeved knit shirts. When it is particularly cold, I add the Cuddleduds long johns.

Electric warming mattress pad heats up my bed much better than an electric blanket. When the heat source is underneath, it works best for me.

Electric heating pads are scattered all around my house. So wherever I am, I can warm myself up. My hands, neck, and knees give me the most problem with being cold. Applying the hot heating pad to the cold spot for a short time is the most workable and effective for me.

I have blue/purple feet much of the time. My polio leg gets cold from the knee down to the foot, while my other leg is warm.

Small Polarfleece mini-blankets are very helpful. All the major discount stores sell them for about $10.00. I bought several and even color coordinated them with my rooms, so they fit in with my décor while keeping me warm.

My body heats more rapidly in hot weather; and cools more rapidly in cold weather. I wear dancers’ leg warmers. Because they are loosely knit, they do not restrict my circulation.

I sew the ends of the warmers shut to create long socks and I wear them all night in bed.

The only way I can get warmed up and stay that way is to use electric powered warmth. I use an electric throw and a small portable electric space heater directed right at my feet.

Hot paraffin wax works for me. I dip my foot into the wax and it feels absolutely wonderful.

My Sunbeam heated throw' - model # 71460 - 20% polyester - 80% acrylic – is my best friend.

When it is really cold and snowy, my feet, legs, and hands suffer. I then have trouble with function of my hands and legs with a steady cramping feeling.

Hot showers work for me. I also use herb filled packs on my feet and hands. These are pads filled with rice and various herbs. You toss them in the microwave to heat up and they stay nice and warm for over an hour.

I get cold all-over, but it is much worse from my knees down. My home is filled with large bath towels, small throws, and knitted ponchos on all the furniture. I use these to toss over my knees and legs.

Since I cannot tolerate any weight on my feet, I use a down-filled comforter to keep me warm while still being lightweight.

In the past few years, my feet and hands get cold even at room temperature. My daily routine is to bathe in the morning, after which my body is warm for hours. When this effect wears off my left leg and the rest of my body slowly begin to cool down.

Since I don’t want to turn the furnace up too high, I find that using a rice bag really helps. It is made of cotton material, sewn into a square shape, and filled with rice through an open corner, and then sealed up. After three minutes in the microwave, the bag stays heated for 30 minutes or longer giving soothing warmth.

My left foot turns bluish when it gets cold. An hour after my warm bath, I can feel my left foot starting to cool. It is a very strange feeling because my right foot feels a bit too warm and the left gets ice cold.

I wear socks to bed and place an afghan over my lower legs. In extremely cold weather, I also use an electric blanket.

Velour blankets (name brand Vellux) are great. They are lightweight and very warm and cuddly.

I purchased several Sunbeam heated throws at Wal-Mart for $15.00 on clearance. Previously I used twin size electric blankets but these were often too big to use sitting in a chair. The throws are a perfect size of 50” x 60”. I take these throws on car trips and even to the hospital when I go.

Cold has troubled me all of my life. When my right hand gets too cold, it becomes weak and hard to straighten out my fingers.

Sheet blankets as both the bottom sheet and top sheet keep me warm. They are not as shockingly cold as regular sheets.

I always have cold legs! I wear leggings under my slacks almost all year long. If I can keep my knees warm, I feel better.

Many a night I have actually wished there was a nurse here to wrap my legs in those smelly, steamy, hot packs again!

Perhaps you would like to purchase some warm performance clothing but it may be too difficult to get out to a mall. If you have Internet access, a solution to consider is web commerce. Below is a list of some reputable online merchants where you will find good insulating clothing. This merchandise is geared to climbing, mountaineering, and other outdoor sports, with features and fabrics ready to meet the harshest of winter mountain conditions. How perfect for polio survivors!

Dear Cats, We need to talk.

1. When I say to move, it means go someplace else, not switch positions with each other so there are still two cats in the way.

2. The dishes with the paw print are yours and contain your food. The other dishes are mine and contain my food. Please note, placing a paw print in the middle of my plate and food does not stake a claim for it becoming your food and dish, nor do I find that aesthetically pleasing in the slightest.

3. The stairway was not designed by NASCAR and is not a racetrack. Beating me to the bottom is not the object. Tripping me doesn't help, because I fall faster than you can run.

4. I cannot buy anything bigger than a king size bed. I am very sorry about this. Do not think I will continue to sleep on the couch to ensure your comfort. Look at videos of cats sleeping; they can actually curl up in a ball. It is not necessary to sleep perpendicular to each other stretched out to the fullest extent possible.

5. I also know that sticking tails straight out and having tongues hanging out the other end to maximize space used is nothing but feline sarcasm.

6. My compact discs are not toys for you and your friends to play with.

7. For the last time, there is not a secret exit from the bathroom. If by some miracle I beat you there and manage to get the door shut, it is not necessary to claw, whine, try to turn the knob, or get your paw under the edge and try to pull the door open. I must exit through the same door I entered. In addition, I have been using bathrooms for years and I know that feline attendance is not mandatory.

8. The proper order is kiss me, then go smell the other cat's butt. I cannot stress this enough. It should be such a simple change for you.

Sincerely,

The Person Who Lives Here (and buys your food).

Minnesota health officials are investigating the death of a person who was infected with a strain of the polio virus.

The patient was infected with the live polio virus that was used in the oral vaccine, which was discontinued in the U.S. in 2000, the Department of Health said Tuesday. The vaccine now in use is injected and doesn't contain live virus, and officials said this case poses no risk to the general public.
"This is a very rare occurrence and does not signal a resurgence of polio," State Epidemiologist Ruth Lynfield said in a statement.
The patient died last month with polio symptoms that included paralysis, but the department said it's not known to what extent polio contributed to the death. The patient also had a weakened immune system and multiple health problems.
It's likely the patient became infected from someone who had received the live-virus vaccine before its use was stopped, the department said. Aaron Devries, an epidemiologist with the department, said testing here and at the Centers for Disease Control and Prevention showed that the patient probably acquired the virus 10 to 15 years ago and continued to carry it around all these years. He said they don't know why the patient became ill from it only recently.
The department said it was working to determine if any health care workers might have been exposed. It said only unvaccinated people or people with deficient immune systems who had direct, ungloved contact with the patient's bodily secretions would be at any risk.
Citing patient privacy laws, the department did not release any details about the victim.
Officials said this type of polio infection is very rare. Only 45 cases of vaccine-derived paralytic polio disease in people with immunodeficiencies have been reported in the world since 1961, according to the Centers for Disease Control and Prevention.
In these rare cases, the health department said, someone who has either never been vaccinated or has a weak immune system can get the polio virus from someone who has been vaccinated and is excreting the virus in their stools. Sometimes, but not always, these infections result in illness, as happened in this case.
The other reported U.S. instances of vaccine-derived polio infection also occurred in Minnesota , in 2005. Five children from the Amish community near Clarissa in central Minnesota , which had low rates of immunization, were infected but did not develop outward symptoms.
Lynfield said they suspect the reason all the U.S. cases were detected in Minnesota was because of its advanced public health reporting system.
The CDC says the oral vaccine is still used in countries where naturally occurring polio is still a threat because it's better at stopping the spread of the virus. The U.S. switched to the injected vaccine because wild polio has already been eliminated from the Western Hemisphere , and the few cases of polio that were occurring, about 8-10 per year, were caused by the oral vaccine itself, not the wild virus.
The last case of naturally occurring paralytic polio occurred in the U.S. in 1979, but health officials said the new case was a reminder for people to make sure their immunizations and their children's shots are current. Most people in the U.S. have been vaccinated against polio.
But vaccination rates against polio are dropping, warned Dr. Richard L. Bruno, chairman of the International Post-Polio Task Force and director of The Post-Polio Institute at New Jersey 's Englewood Hospital and Medical Center . He noted that the CDC estimates that more than 1 million U.S. toddlers aren't vaccinated against it. And he said there's always a danger polio could return via another country where it's endemic.
"We must do more to vaccinate America 's children against this deadly and disabling disease," Bruno said. " America 's next polio epidemic could be just a car or plane ride away."

INTERNATIONAL
POST-POLIO TASK FORCE
International Centre for Post-Polio Education and Research
at Englewood Hospital and Medical Center
Englewood, New Jersey 07631 USA
877-Post-Polio 201-894-3724
PostPolioInfo@aol.com
PostPolioInfo.com

Tuesday April 14, 2009: The Associate Press today reported the death of a person infected with the live poliovirus used in the oral vaccine that was discontinued in the US nine years ago. The health department says the patient died with polio symptoms, but it's not known to what extent polio contributed to the death. The patient also had a weakened immune system and multiple health problems. The Minnesota department of health says the patient most likely became infected from someone who had received the live-virus vaccine before its use was stopped.

"For reasons we don't understand, the live poliovirus remained inside this person for ten years, mutated and became virulent, then contributed to the person’s death,” said Dr. Richard Bruno, chairperson of the International Post-Polio Task Force. "This death is the latest sad reminder that polio may be forgotten in the US , but that it is far from gone.”

Alarming Drops in Polio Vaccination in US Border States and Ports of Entry.

Unfortunately, rates of polio vaccination have decreased in the US in spite of six other US polio cases since 2005 -- five of them in Minnesota -- caused by poliovirus imported into the US, and in spite of polio breaking free of vaccination efforts last month in Africa, with Kenya and Uganda reporting their first polio cases and deaths in twenty years.

“The latest Centers for Disease Control data show drops in polio vaccination in twenty states and in ten large US cities," said Dr. Bruno, who is also director of The Post-Polio Institute at Englewood Hospital and Medical Center . “The CDC estimates that more than one million US toddlers are unvaccinated."

“Even Minnesota has had a decrease in polio vaccination, which is obviously disturbing,” said Dr. Bruno. “It is frightening that states with the largest drops lie next to Mexico and Canada , across whose borders the poliovirus is believed to have been imported into the US since 1997.” Seventy percent of the states that border Canada had drops in polio vaccination as did Arizona , Texas and New Mexico .

City Children Living in Poverty Have Lowest Polio Vaccination Rates.

Dr. Bruno is also concerned about cities that are major points of entry into the US -- New York , Philadelphia , Houston and Seattle -- where drops in polio vaccination were also reported.

“Toddlers living in poverty have the lowest polio vaccination rates -- below 87% in Boston , Indianapolis , Memphis and Phoenix , and below 85% in Detroit , Houston and Seattle -- rates lower than in Western Pacific countries that include Cambodia , Mongolia and Vietnam ,” said Dr. Bruno. "I’m worried that those who recently had polio in the US are canaries in the mine shaft."

"NIPP IT YEAR” Underscored by Minnesota Death.

The International Post-Polio Task Force proclaimed 2008-2009 “National Immunization for Polio Prevention in Infants and Toddlers -- or ‘NIPP IT’ -- YEAR,” to prompt parents, healthcare professionals and state health officials to ensure that all American children receive four doses of the injectable, inactivated polio vaccine by age two.

“‘NIPP IT YEAR’ is intended to raise awareness of the need for polio vaccination, to stop state legislatures from allowing parents to refuse vaccinations for their children because of a “philosophically objection” to vaccines, and hopefully ‘nip’ America’s next polio epidemic in the bud,” said Dr. Bruno.

The polio vaccine has been a victim of its own success. Young parents do not vaccinate because they have not experienced the devastation, death and disability caused by diseases vaccines eliminated, or are unaware that polio remains a scourge transportable from Africa, Pakistan , Afghanistan and India .

"With the ease of air travel, what will happen when a polio-infected individual lands in one of America's potential polio pockets, like New York City, and passes poliovirus to the estimated 24,000 infants and toddlers in that city who are not immunized?” asked Dr. Bruno “We must do more to vaccinate America's children against this deadly and disabling disease. America 's next polio epidemic could be just a car or plane ride away."

An excerpt from the Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors

Pain can be due to any number of factors ranging from very benign to quite serious. Polio survivors who are experiencing pain should undergo a comprehensive medical evaluation to diagnose its cause. Pain is most often due to overuse of muscles, tendons, ligaments and/or joints, and primary interventions are directed at alleviating or eliminating the overuse factors.

Pain syndromes associated with the late effects of polio include muscle (myogenic) pain and cramping. Fasciculations, often described as a crawling sensation, are exacerbated by physical activity, stress and sometimes cold weather. Typically, myogenic pain and fasciculations will decrease or disappear entirely with restGentle stretching may be useful, but must be performed judiciously in situations when there is a greater functional benefit with tighter tendons (Gawne, 1997). Heat and gentle massage are useful adjunctive treatments as well. Fibromyalgia and its associated pain have been noted to be more prevalent among polio survivors (Trojan & Cashman, 1995).

Strain injuries are not uncommon and affect the muscles, tendons, bursa and ligaments, and may occur chronically or acutely. Pain due to strain may be related to posture and/or occur as a result of overuse of the arms, shoulders and lower extremities (Smith & McDermott, 1987). Pain radiating from the shoulders is a result of supraspinatus or biceps tendinitis. Elbow pain is common, as is knee pain. Genu recurvatum (back knee) is a condition in which, because of weakness of the ligaments and muscles around the knee, there is progressive backward deformity of the knee. To control or eliminate strain injuries and symptoms, the joints should be protected by bracing or by a decrease in crutch use.

Another frequent cause of pain is degenerative joint disease. Degenerative changes, also in the spine, are exacerbated by weakened muscles and worsened by walking on unprotected joints with unusual gait movements and abnormal stresses. They can be lessened by improving support with appropriate bracing, adaptive devices (canes, crutches, corsets), special seating and postural modification.

Other pain problems that can occur are secondary nerve compression syndromes, commonly at the wrist and occasionally at the elbows (Werner & Waring, 1989). Median nerve compression, at the wrist (carpal tunnel syndrome), and ulnar nerve compression, at the elbow and wrist, are more prevalent in those who are crutch or manual wheelchair users than in the general population. Stress on the wrist and elbow can be reduced by using power carts, three-wheeled scooters, power chairs and/or by using hand splints.

A common site of pain in polio survivors, as a result of using a backward-sideward trunk lurch to substitute for weak hip muscles, is the lower back. Abnormal trunk movements transfer body weight to the small facet joints at the back of the vertebra, and they cannot tolerate the strain. The concentration of back motion at one level in the low back due to a spinal fusion or scoliosis is another cause of back pain.

Weak abdominal muscles also predispose one to chronic back strain and back injury. Abdominal binders, corsets or girdles can help substitute for weak abdominal muscles. Individuals who depend on excessive lumbosacral motion for walking may not tolerate certain corsets.

Physical therapy such as heat, massage, joint mobilization and stretching exercises can help control or resolve low back pain. A change in posture and gait pattern, such as using crutches or a rolling walker, may be needed to prevent recurrence or to resolve chronic pain. Due to increasing muscle weakness and muscle imbalance, some people may need to use a three-wheeled scooter or wheelchair to control this type of chronic pain.

Radiculopathy (disease of the nerve roots) may be the cause of pain in some polio survivors, particularly those who have abnormal posture and/or severe scoliosis, or neck or low back hyperextension due to trunk weakness. A body corset or body brace, if not being worn, may be an option in some cases, as is improved seating position. In other cases, traction and therapeutic modalities (ice, heat, massage, ultrasound, transcutaneous electrical nerve stimulation [TENS] and trigger point injections) may be beneficial. Symptomatic treatment with medications such as nonsteroidal anti-inflammatories (see Medications) may also be helpful, but their long-term use should be avoided. Surgery may also be needed in select severe cases.

Pain syndromes associated with the late effects of polio include muscle (myogenic) pain and cramping. Fasciculations, often described as a crawling sensation, are exacerbated by physical activity, stress and sometimes cold weather. Typically, myogenic pain and fasciculations will decrease or disappear entirely with rest.Gentle stretching may be useful, but must be performed judiciously in situations when there is a greater functional benefit with tighter tendons (Gawne, 1997). Heat and gentle massage are useful adjunctive treatments as well. Fibromyalgia and its associated pain have been noted to be more prevalent among polio survivors (Trojan & Cashman, 1995).

Musculoskeletal pain in polio survivors and strength-matched controls.

Moss Rehabilitation Research Institute, Philadelphia, PA, USA. mklein@einstein.edu

OBJECTIVES: To determine whether a significant difference exists between musculoskeletal symptoms of polio survivors and those of older adults with no history of polio, and to determine if activity level and strength predict pain in either group. DESIGN: Matched research design. SETTING: A research laboratory in a rehabilitation setting. PARTICIPANTS: Fifty-four polio survivors and 54 adults with no history of polio were matched for gender, race, and bilateral knee extensor strength and selected from a cohort of 316 subjects who participated in a study on the relation between activity level and health status. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Location and severity of musculoskeletal pain, activity frequency and intensity level, maximum voluntary isometric strength, and physical performance measures. RESULTS: Polio survivors reported significantly more symptoms than the matched controls ( P <.05). Symptom status among the polio survivors was strongly associated with performance strain, perceived exertion, and activity intensity. Although the polio survivors had activity frequencies and habitual walking speeds that were similar to those from the matched controls, there was evidence that they performed activities at higher intensity levels. CONCLUSIONS: Activity level is a factor in the development of musculoskeletal symptoms in polio survivors. Polio survivors who perform at higher intensity levels are more likely to have moderate to severe pain and more mobility difficulties.

As if we need an introduction!! This is a lengthy article covering all types of pain - not only spinal or polio related, and I publish the entire article in a single issue because pain is our constant companion, and I believe that many of us will read it with interest. Ed.

You know it at once. It may be the fiery sensation of a burn moments after your finger touches the stove. Or it's a dull ache above your brow after a day of stress and tension. Or you may recognize it as a sharp pierce in your back after you lift something heavy.

It is pain. In its most benign form, it warns us that something isn't quite right, that we should take medicine or see a doctor. At its worst, however, pain robs us of our productivity, our well-being, and, for many of us suffering from extended illness, our very lives. Pain is a complex perception that differs enormously among individual patients, even those who appear to have identical injuries or illnesses.

In 1931, the French medical missionary Dr. Albert Schweitzer wrote, "Pain is a more terrible lord of mankind than even death itself." Today, pain has become the universal disorder, a serious and costly public health issue, and a challenge for family, friends, and health care providers who must give support to the individual suffering from the physical as well as the emotional consequences of pain.

A Brief History of Pain

Ancient civilizations recorded on stone tablets accounts of pain and the treatments used: pressure, heat, water, and sun. Early humans related pain to evil, magic, and demons. Relief of pain was the responsibility of sorcerers, shamans, priests, and priestesses, who used herbs, rites, and ceremonies as their treatments.

The Greeks and Romans were the first to advance a theory of sensation, the idea that the brain and nervous system have a role in producing the perception of pain. But it was not until the Middle Ages and well into the Renaissance-the 1400s and 1500s-that evidence began to accumulate in support of these theories. Leonardo da Vinci and his contemporaries came to believe that the brain was the central organ responsible for sensation. Da Vinci also developed the idea that the spinal cord transmits sensations to the brain.

In the 17th and 18th centuries, the study of the body-and the senses-continued to be a source of wonder for the world's philosophers. In 1664, the French philosopher René Descartes described what to this day is still called a "pain pathway." Descartes illustrated how particles of fire, in contact with the foot, travel to the brain and he compared pain sensation to the ringing of a bell.

In the 19th century, pain came to dwell under a new domain-science-paving the way for advances in pain therapy. Physician-scientists discovered that opium, morphine, codeine, and cocaine could be used to treat pain. These drugs led to the development of aspirin, to this day the most commonly used pain reliever. Before long, anesthesia-both general and regional-was refined and applied during surgery.

"It has no future but itself," wrote the 19th century American poet Emily Dickinson, speaking about pain. As the 21st century unfolds, however, advances in pain research are creating a less grim future than that portrayed in Dickinson’s verse, a future that includes a better understanding of pain, along with greatly improved treatments to keep it in check.

What is pain? The International Association for the Study of Pain defines it as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

It is useful to distinguish between two basic types of pain, acute and chronic, and they differ greatly.

Hundreds of pain syndromes or disorders make up the spectrum of pain. There are the most benign, fleeting sensations of pain, such as a pin prick. There is the pain of childbirth, the pain of a heart attack, and the pain that sometimes follows amputation of a limb. There is also pain accompanying cancer and the pain that follows severe trauma, such as that associated with head and spinal cord injuries. A sampling of common pain syndromes follows, listed alphabetically.

Arachnoiditis is a condition in which one of the three membranes covering the brain and spinal cord, called the arachnoid membrane, becomes inflamed. A number of causes, including infection or trauma, can result in inflammation of this membrane. Arachnoiditis can produce disabling, progressive, and even permanent pain.

Arthritis. Millions of Americans suffer from arthritic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout. These disorders are characterized by joint pain in the extremities. Many other inflammatory diseases affect the body's soft tissues, including tendonitis and bursitis.

Back pain has become the high price paid by our modern lifestyle and is a startlingly common cause of disability for many Americans, including both active and inactive people. Back pain that spreads to the leg is called sciatica and is a very common condition Another common type of back pain is associated with the discs of the spine, the soft, spongy padding between the vertebrae (bones) that form the spine. Discs protect the spine by absorbing shock, but they tend to degenerate over time and may sometimes rupture. Spondylolisthesis is a back condition that occurs when one vertebra extends over another, causing pressure on nerves and therefore pain. Also, damage to nerve roots is a serious condition, called radiculopathy, that can be extremely painful. Treatment for a damaged disc includes drugs such as painkillers, muscle relaxants, and steroids; exercise or rest, depending on the patient's condition; adequate support, such as a brace or better mattress and physical therapy. In some cases, surgery may be required to remove the damaged portion of the disc and return it to its previous condition, especially when it is pressing a nerve root. Surgical procedures include discectomy, laminectomy, or spinal fusion

Burn pain can be profound and poses an extreme challenge to the medical community. First-degree burns are the least severe; with third-degree burns, the skin is lost. Depending on the injury, pain accompanying burns can be excruciating, and even after the wound has healed patients may have chronic pain at the burn site.

Cancer pain can accompany the growth of a tumor, the treatment of cancer, or chronic problems related to cancer's permanent effects on the body. Fortunately, most cancer pain can be treated to help minimize discomfort and stress to the patient.

Headaches affect millions of Americans. The three most common types of chronic headache are migraines, cluster headaches, and tension headaches. Each comes with its own telltale brand of pain.

Head and facial pain can be agonizing, whether it results from dental problems or from disorders such as cranial neuralgia, in which one of the nerves in the face, head, or neck is inflamed. Another condition, trigeminal neuralgia (also called tic douloureux), affects the largest of the cranial nerves and is characterized by a stabbing, shooting pain.

Muscle pain can range from an aching muscle, spasm, or strain, to the severe spasticity that accompanies paralysis. Another disabling syndrome is fibromyalgia, a disorder characterized by fatigue, stiffness, joint tenderness, and widespread muscle pain. Polymyositis, dermatomyositis, and inclusion body myositis are painful disorders characterized by muscle inflammation. They may be caused by infection or autoimmune dysfunction and are sometimes associated with connective tissue disorders, such as lupus and rheumatoid arthritis.

Myofascial pain syndromes affect sensitive areas known as trigger points, located within the body's muscles. Myofascial pain syndromes are sometimes misdiagnosed and can be debilitating. Fibromyalgia is a type of myofascial pain syndrome.

Neuropathic pain is a type of pain that can result from injury to nerves, either in the peripheral or central nervous system. Neuropathic pain can occur in any part of the body and is frequently described as a hot, burning sensation, which can be devastating to the affected individual. It can result from diseases that affect nerves (such as diabetes) or from trauma, or, because chemotherapy drugs can affect nerves, it can be a consequence of cancer treatment. Among the many neuropathic pain conditions are diabetic neuropathy (which results from nerve damage secondary to vascular problems that occur with diabetes); reflex sympathetic dystrophy syndrome, which can follow injury; phantom limb and post-amputation pain, which can result from the surgical removal of a limb; postherpetic neuralgia, which can occur after an outbreak of shingles; and central pain syndrome, which can result from trauma to the brain or spinal cord.

Reflex sympathetic dystrophy syndrome, or RSDS, is accompanied by burning pain and hypersensitivity to temperature. Often triggered by trauma or nerve damage, RSDS causes the skin of the affected area to become characteristically shiny. In recent years, RSDS has come to be called complex regional pain syndrome (CRPS); in the past it was often called causalgia.

Repetitive stress injuries are muscular conditions that result from repeated motions performed in the course of normal work or other daily activities. They include:

Sciatica is a painful condition caused by pressure on the sciatic nerve, the main nerve that branches off the spinal cord and continues down into the thighs, legs, ankles, and feet. Sciatica is characterized by pain in the buttocks and can be caused by a number of factors. Exertion, obesity, and poor posture can all cause pressure on the sciatic nerve. One common cause of sciatica is a herniated disc.

Shingles and other painful disorders affect the skin. Pain is a common symptom of many skin disorders, even the most common rashes. One of the most vexing neurological disorders is shingles or herpes zoster, an infection that often causes agonizing pain resistant to treatment. Prompt treatment with antiviral agents is important to arrest the infection, which if prolonged can result in an associated condition known as postherpetic neuralgia. Other painful disorders affecting the skin include:

Sports injuries are common. Sprains, strains, bruises, dislocations, and fractures are all well-known words in the language of sports. Pain is another. In extreme cases, sports injuries can take the form of costly and painful spinal cord and head injuries, which cause severe suffering and disability.

Spinal stenosis refers to a narrowing of the canal surrounding the spinal cord. The condition occurs naturally with aging. Spinal stenosis causes weakness in the legs and leg pain usually felt while the person is standing up and often relieved by sitting down.

Surgical pain may require regional or general anesthesia during the procedure and medications to control discomfort following the operation. Control of pain associated with surgery includes presurgical preparation and careful monitoring of the patient during and after the procedure.

Temporomandibular disorders are conditions in which the temporomandibular joint (the jaw) is damaged and/or the muscles used for chewing and talking become stressed, causing pain. The condition may be the result of a number of factors, such as an injury to the jaw or joint misalignment, and may give rise to a variety of symptoms, most commonly pain in the jaw, face, and/or neck muscles. Physicians reach a diagnosis by listening to the patient's description of the symptoms and by performing a simple examination of the facial muscles and the temporomandibular joint.

Trauma can occur after injuries in the home, at the workplace, during sports activities, or on the road. Any of these injuries can result in severe disability and pain. Some patients who have had an injury to the spinal cord experience intense pain ranging from tingling to burning and, commonly, both. Such patients are sensitive to hot and cold temperatures and touch. For these individuals, a touch can be perceived as intense burning, indicating abnormal signals relayed to and from the brain. This condition is called central pain syndrome or, if the damage is in the thalamus (the brain's center for processing bodily sensations), thalamic pain syndrome. It affects as many as 100,000 Americans with multiple sclerosis, Parkinson's disease, amputated limbs, spinal cord injuries, and stroke. Their pain is severe and is extremely difficult to treat effectively. A variety of medications, including analgesics, antidepressants, anticonvulsants, and electrical stimulation, are options available to central pain patients.

Vascular disease or injury-such as vasculitis or inflammation of blood vessels, coronary artery disease, and circulatory problems-all have the potential to cause pain. Vascular pain affects millions of Americans and occurs when communication between blood vessels and nerves is interrupted. Ruptures, spasms, constriction, or obstruction of blood vessels, as well as a condition called ischemia in which blood supply to organs, tissues, or limbs is cut off, can also result in pain.

How is Pain Diagnosed?

There is no way to tell how much pain a person has. No test can measure the intensity of pain, no imaging device can show pain, and no instrument can locate pain precisely. Sometimes, as in the case of headaches, physicians find that the best aid to diagnosis is the patient's own description of the type, duration, and location of pain. Defining pain as sharp or dull, constant or intermittent, burning or aching may give the best clues to the cause of pain. These descriptions are part of what is called the pain history, taken by the physician during the preliminary examination of a patient with pain.

Physicians, however, do have a number of technologies they use to find the cause of pain. Primarily these include:

Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. Information from EMG can help physicians tell precisely which muscles or nerves are affected by weakness or pain. Thin needles are inserted in muscles and a physician can see or listen to electrical signals displayed on an EMG machine. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock that stimulates the nerve that runs to that muscle. The second set of electrodes is used to make a recording of the nerve's electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes-one set for stimulating a nerve (these electrodes are attached to a limb) and another set on the scalp for recording the speed of nerve signal transmission to the brain.

How is Pain Treated?

The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable. The following treatments are among the most common.

Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).

Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators.

Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.

Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.

Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs.

Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.

Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness.

Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.

Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams.

Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure's use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain.

Chiropractic care may ease back pain, neck pain, headaches, and musculoskeletal conditions. It involves "hands-on" therapy designed to adjust the relationship between the body's structure (mainly the spine) and its functioning. Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and adjacent tissues. Such care may also involve therapeutic and rehabilitative exercises.

Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.

Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.

COX-2 inhibitors may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins, which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs.

In 1999, the Food and Drug Administration approved a COX-2 inhibitor-celecoxib-for use in cases of chronic pain. The long-term effects of all COX-2 inhibitors are still being evaluated, especially in light of new information suggesting that these drugs may increase the risk of heart attack and stroke. Patients taking any of the COX-2 inhibitors should review their drug treatment with their doctors.

Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:

Exercise has come to be a prescribed part of some doctors' treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, that patients carefully follow the routine laid out by their physicians.

Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.

Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.

Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.

Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.

Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade.

Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.

Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting.

Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery.

Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain's own analgesics and setting the body's self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value.

R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.

Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient's pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.

Gender and Pain

It is now widely believed that pain affects men and women differently. While the sex hormones estrogen and testosterone certainly play a role in this phenomenon, psychology and culture, too, may account at least in part for differences in how men and women receive pain signals. For example, young children may learn to respond to pain based on how they are treated when they experience pain. Some children may be cuddled and comforted, while others may be encouraged to tough it out and to dismiss their pain.

Many investigators are turning their attention to the study of gender differences and pain. Women, many experts now agree, recover more quickly from pain, seek help more quickly for their pain, and are less likely to allow pain to control their lives. They also are more likely to marshal a variety of resources-coping skills, support, and distraction-with which to deal with their pain.

Research in this area is yielding fascinating results. For example, male experimental animals injected with estrogen, a female sex hormone, appear to have a lower tolerance for pain-that is, the addition of estrogen appears to lower the pain threshold. Similarly, the presence of testosterone, a male hormone, appears to elevate tolerance for pain in female mice: the animals are simply able to withstand pain better. Female mice deprived of estrogen during experiments react to stress similarly to male animals. Estrogen, therefore, may act as a sort of pain switch, turning on the ability to recognize pain.

Investigators know that males and females both have strong natural pain-killing systems, but these systems operate differently. For example, a class of painkillers called kappa-opioids is named after one of several opioid receptors to which they bind, the kappa-opioid receptor, and they include the compounds nalbuphine (Nubain®) and butorphanol (Stadol®). Research suggests that kappa-opioids provide better pain relief in women.

Though not prescribed widely, kappa-opioids are currently used for relief of labor pain and in general work best for short-term pain. Investigators are not certain why kappa-opioids work better in women than men. Is it because a woman's estrogen makes them work, or because a man's testosterone prevents them from working? Or is there another explanation, such as differences between men and women in their perception of pain? Continued research may result in a better understanding of how pain affects women differently from men, enabling new and better pain medications to be designed with gender in mind.

Pain in Aging and Pediatric Populations: Special Needs and Concerns

Pain is the number one complaint of older Americans, and one in five older Americans takes a painkiller regularly. In 1998, the American Geriatrics Society (AGS) issued guidelines for the management of pain in older people. The AGS panel addressed the incorporation of several non-drug approaches in patients' treatment plans, including exercise. AGS panel members recommend that, whenever possible, patients use alternatives to aspirin, ibuprofen, and other NSAIDs because of the drugs' side effects, including stomach irritation and gastrointestinal bleeding. For older adults, acetaminophen is the first-line treatment for mild-to-moderate pain, according to the guidelines. More serious chronic pain conditions may require opioid drugs (narcotics), including codeine or morphine, for relief of pain.

Pain in younger patients also requires special attention, particularly because young children are not always able to describe the degree of pain they are experiencing. Although treating pain in pediatric patients poses a special challenge to physicians and parents alike, pediatric patients should never be undertreated. Recently, special tools for measuring pain in children have been developed that, when combined with cues used by parents, help physicians select the most effective treatments.

Nonsteroidal agents, and especially acetaminophen, are most often prescribed for control of pain in children. In the case of severe pain or pain following surgery, acetaminophen may be combined with codeine.

We may experience pain as a prick, tingle, sting, burn, or ache. Receptors on the skin trigger a series of events, beginning with an electrical impulse that travels from the skin to the spinal cord. The spinal cord acts as a sort of relay center where the pain signal can be blocked, enhanced, or otherwise modified before it is relayed to the brain. One area of the spinal cord in particular, called the dorsal horn, is important in the reception of pain signals.

The most common destination in the brain for pain signals is the thalamus and from there to the cortex, the headquarters for complex thoughts. The thalamus also serves as the brain's storage area for images of the body and plays a key role in relaying messages between the brain and various parts of the body. In people who undergo an amputation, the representation of the amputated limb is stored in the thalamus.

Pain is a complicated process that involves an intricate interplay between a number of important chemicals found naturally in the brain and spinal cord. In general, these chemicals, called neurotransmitters, transmit nerve impulses from one cell to another.

There are many different neurotransmitters in the human body; some play a role in human disease and, in the case of pain, act in various combinations to produce painful sensations in the body. Some chemicals govern mild pain sensations; others control intense or severe pain.

The body's chemicals act in the transmission of pain messages by stimulating neurotransmitter receptors found on the surface of cells; each receptor has a corresponding neurotransmitter. Receptors function much like gates or ports and enable pain messages to pass through and on to neighboring cells. One brain chemical of special interest to neuroscientists is glutamate. During experiments, mice with blocked glutamate receptors show a reduction in their responses to pain. Other important receptors in pain transmission are opiate-like receptors. Morphine and other opioid drugs work by locking on to these opioid receptors, switching on pain-inhibiting pathways or circuits, and thereby blocking pain.

Another type of receptor that responds to painful stimuli is called a nociceptor. Nociceptors are thin nerve fibers in the skin, muscle, and other body tissues, that, when stimulated, carry pain signals to the spinal cord and brain. Normally, nociceptors only respond to strong stimuli such as a pinch. However, when tissues become injured or inflamed, as with a sunburn or infection, they release chemicals that make nociceptors much more sensitive and cause them to transmit pain signals in response to even gentle stimuli such as breeze or a caress. This condition is called allodynia -a state in which pain is produced by innocuous stimuli.

The body's natural painkillers may yet prove to be the most promising pain relievers, pointing to one of the most important new avenues in drug development. The brain may signal the release of painkillers found in the spinal cord, including serotonin, norepinephrine, and opioid-like chemicals. Many pharmaceutical companies are working to synthesize these substances in laboratories as future medications.

Endorphins and enkephalins are other natural painkillers. Endorphins may be responsible for the "feel good" effects experienced by many people after rigorous exercise; they are also implicated in the pleasurable effects of smoking.

Similarly, peptides, compounds that make up proteins in the body, play a role in pain responses. Mice bred experimentally to lack a gene for two peptides called tachykinins-neurokinin A and substance P-have a reduced response to severe pain. When exposed to mild pain, these mice react in the same way as mice that carry the missing gene. But when exposed to more severe pain, the mice exhibit a reduced pain response. This suggests that the two peptides are involved in the production of pain sensations, especially moderate-to-severe pain. Continued research on tachykinins, conducted with support from the NINDS, may pave the way for drugs tailored to treat different severities of pain.

Scientists are working to develop potent pain-killing drugs that act on receptors for the chemical acetylcholine. For example, a type of frog native to

Ecuador

has been found to have a chemical in its skin called epibatidine, derived from the frog's scientific name, Epipedobates tricolor. Although highly toxic, epibatidine is a potent analgesic and, surprisingly, resembles the chemical nicotine found in cigarettes. Also under development are other less toxic compounds that act on acetylcholine receptors and may prove to be more potent than morphine but without its addictive properties.

The idea of using receptors as gateways for pain drugs is a novel idea, supported by experiments involving substance P. Investigators have been able to isolate a tiny population of neurons, located in the spinal cord, that together form a major portion of the pathway responsible for carrying persistent pain signals to the brain. When animals were given injections of a lethal cocktail containing substance P linked to the chemical saporin, this group of cells, whose sole function is to communicate pain, were killed. Receptors for substance P served as a portal or point of entry for the compound. Within days of the injections, the targeted neurons, located in the outer layer of the spinal cord along its entire length, absorbed the compound and were neutralized. The animals' behavior was completely normal; they no longer exhibited signs of pain following injury or had an exaggerated pain response. Importantly, the animals still responded to acute, that is, normal, pain. This is a critical finding as it is important to retain the body's ability to detect potentially injurious stimuli. The protective, early warning signal that pain provides is essential for normal functioning. If this work can be translated clinically, humans might be able to benefit from similar compounds introduced, for example, through lumbar (spinal) puncture.

Another promising area of research using the body's natural pain-killing abilities is the transplantation of chromaffin cells into the spinal cords of animals bred experimentally to develop arthritis. Chromaffin cells produce several of the body's pain-killing substances and are part of the adrenal medulla, which sits on top of the kidney. Within a week or so, rats receiving these transplants cease to exhibit telltale signs of pain. Scientists, working with support from the NINDS, believe the transplants help the animals recover from pain-related cellular damage. Extensive animal studies will be required to learn if this technique might be of value to humans with severe pain.

One way to control pain outside of the brain, that is, peripherally, is by inhibiting hormones called prostaglandins. Prostaglandins stimulate nerves at the site of injury and cause inflammation and fever. Certain drugs, including NSAIDs, act against such hormones by blocking the enzyme that is required for their synthesis.

Blood vessel walls stretch or dilate during a migraine attack and it is thought that serotonin plays a complicated role in this process. For example, before a migraine headache, serotonin levels fall. Drugs for migraine include the triptans: sumatriptan (Imitrix®), naratriptan (Amerge®), and zolmitriptan (Zomig®). They are called serotonin agonists because they mimic the action of endogenous (natural) serotonin and bind to specific subtypes of serotonin receptors.

Ongoing pain research, much of it supported by the NINDS, continues to reveal at an unprecedented pace fascinating insights into how genetics, the immune system, and the skin contribute to pain responses.

The explosion of knowledge about human genetics is helping scientists who work in the field of drug development. We know, for example, that the pain-killing properties of codeine rely heavily on a liver enzyme, CYP2D6, which helps convert codeine into morphine. A small number of people genetically lack the enzyme CYP2D6; when given codeine, these individuals do not get pain relief. CYP2D6 also helps break down certain other drugs. People who genetically lack CYP2D6 may not be able to cleanse their systems of these drugs and may be vulnerable to drug toxicity. CYP2D6 is currently under investigation for its role in pain.

In his research, the late John C. Liebeskind, a renowned pain expert and a professor of psychology at UCLA, found that pain can kill by delaying healing and causing cancer to spread. In his pioneering research on the immune system and pain, Dr. Liebeskind studied the effects of stress-such as surgery-on the immune system and in particular on cells called natural killer or NK cells. These cells are thought to help protect the body against tumors. In one study conducted with rats, Dr. Liebeskind found that, following experimental surgery, NK cell activity was suppressed, causing the cancer to spread more rapidly. When the animals were treated with morphine, however, they were able to avoid this reaction to stress.

The link between the nervous and immune systems is an important one. Cytokines, a type of protein found in the nervous system, are also part of the body's immune system, the body's shield for fighting off disease. Cytokines can trigger pain by promoting inflammation, even in the absence of injury or damage. Certain types of cytokines have been linked to nervous system injury. After trauma, cytokine levels rise in the brain and spinal cord and at the site in the peripheral nervous system where the injury occurred. Improvements in our understanding of the precise role of cytokines in producing pain, especially pain resulting from injury, may lead to new classes of drugs that can block the action of these substances.

What is the Future of Pain Research?

In the forefront of pain research are scientists supported by the National Institutes of Health (NIH), including the NINDS. Other institutes at NIH that support pain research include the National Institute of Dental and Craniofacial Research, the National Cancer Institute, the National Institute of Nursing Research, the National Institute on Drug Abuse, and the National Institute of Mental Health. Developing better pain treatments is the primary goal of all pain research being conducted by these institutes.

Some pain medications dull the patient's perception of pain. Morphine is one such drug. It works through the body's natural pain-killing machinery, preventing pain messages from reaching the brain. Scientists are working toward the development of a morphine-like drug that will have the pain-deadening qualities of morphine but without the drug's negative side effects, such as sedation and the potential for addiction. Patients receiving morphine also face the problem of morphine tolerance, meaning that over time they require higher doses of the drug to achieve the same pain relief. Studies have identified factors that contribute to the development of tolerance; continued progress in this line of research should eventually allow patients to take lower doses of morphine.

One objective of investigators working to develop the future generation of pain medications is to take full advantage of the body's pain "switching center" by formulating compounds that will prevent pain signals from being amplified or stop them altogether. Blocking or interrupting pain signals, especially when there is no injury or trauma to tissue, is an important goal in the development of pain medications. An increased understanding of the basic mechanisms of pain will have profound implications for the development of future medicines. The following areas of research are bringing us closer to an ideal pain drug.

Systems and Imaging: The idea of mapping cognitive functions to precise areas of the brain dates back to phrenology, the now archaic practice of studying bumps on the head. Positron emission tomography (PET), functional magnetic resonance imaging (fMRI), and other imaging technologies offer a vivid picture of what is happening in the brain as it processes pain. Using imaging, investigators can now see that pain activates at least three or four key areas of the brain's cortex-the layer of tissue that covers the brain. Interestingly, when patients undergo hypnosis so that the unpleasantness of a painful stimulus is not experienced, activity in some, but not all, brain areas is reduced. This emphasizes that the experience of pain involves a strong emotional component as well as the sensory experience, namely the intensity of the stimulus.

Channels: The frontier in the search for new drug targets is represented by channels. Channels are gate-like passages found along the membranes of cells that allow electrically charged chemical particles called ions to pass into the cells. Ion channels are important for transmitting signals through the nerve's membrane. The possibility now exists for developing new classes of drugs, including pain cocktails that would act at the site of channel activity.

Trophic Factors: A class of "rescuer" or "restorer" drugs may emerge from our growing knowledge of trophic factors, natural chemical substances found in the human body that affect the survival and function of cells. Trophic factors also promote cell death, but little is known about how something beneficial can become harmful. Investigators have observed that an over-accumulation of certain trophic factors in the nerve cells of animals results in heightened pain sensitivity, and that some receptors found on cells respond to trophic factors and interact with each other. These receptors may provide targets for new pain therapies.

Molecular Genetics: Certain genetic mutations can change pain sensitivity and behavioral responses to pain. People born genetically insensate to pain-that is, individuals who cannot feel pain-have a mutation in part of a gene that plays a role in cell survival. Using "knockout" animal models-animals genetically engineered to lack a certain gene-scientists are able to visualize how mutations in genes cause animals to become anxious, make noise, rear, freeze, or become hypervigilant. These genetic mutations cause a disruption or alteration in the processing of pain information as it leaves the spinal cord and travels to the brain. Knockout animals can be used to complement efforts aimed at developing new drugs.

Plasticity: Following injury, the nervous system undergoes a tremendous reorganization. This phenomenon is known as plasticity. For example, the spinal cord is "rewired" following trauma as nerve cell axons make new contacts, a phenomenon known as "sprouting." This in turn disrupts the cells' supply of trophic factors. Scientists can now identify and study the changes that occur during the processing of pain. For example, using a technique called polymerase chain reaction, abbreviated PCR, scientists can study the genes that are induced by injury and persistent pain. There is evidence that the proteins that are ultimately synthesized by these genes may be targets for new therapies. The dramatic changes that occur with injury and persistent pain underscore that chronic pain should be considered a disease of the nervous system, not just prolonged acute pain or a symptom of an injury. Thus, scientists hope that therapies directed at preventing the long-term changes that occur in the nervous system will prevent the development of chronic pain conditions.

Neurotransmitters: Just as mutations in genes may affect behavior, they may also affect a number of neurotransmitters involved in the control of pain. Using sophisticated imaging technologies, investigators can now visualize what is happening chemically in the spinal cord. From this work, new therapies may emerge, therapies that can help reduce or obliterate severe or chronic pain.

Hope for the Future

Thousands of years ago, ancient peoples attributed pain to spirits and treated it with mysticism and incantations. Over the centuries, science has provided us with a remarkable ability to understand and control pain with medications, surgery, and other treatments. Today, scientists understand a great deal about the causes and mechanisms of pain, and research has produced dramatic improvements in the diagnosis and treatment of a number of painful disorders. For people who fight every day against the limitations imposed by pain, the work of NINDS-supported scientists holds the promise of an even greater understanding of pain in the coming years. Their research offers a powerful weapon in the battle to prolong and improve the lives of people with pain: hope.

Common sense is the most evenly distributed quantity in the world. Everyone thinks he has enough.

Apoptotic signaling cascades operating in poliovirus-infected cells.
Blondel B, Autret A, Brisac C, Martin-Latil S, Mousson L, Pelletier I, Estaquier J, Colbere-Garapin F.
Biologie des Virus Enteriques, Institut Pasteur, 28 rue du Docteur Roux, 75724 Paris cedex 15, France. bblondel@pasteur.fr
Note: For those who might not know what Apoptosis is.... it is the death of a cell.

The flaccid paralyses characteristic of poliomyelitis are a direct consequence of the infection of motor neurons with poliovirus (PV). In PV-infected mice, motor neurons die by apoptosis. However, the mechanisms by which PV induces cell dearh in neurons remain unclear.
Analyses of the apoptotic pathways induced by PV infection in several cell lines have demonstrated that mitochondria (the cell's power sources..... Ed) play a key role in PV- induced apoptosis.
Furthermore, mitochondrial dysfunction results from an imbalance between pro- and anti-apoptotic pathways.

We present here an overview of the many studies of PV-induced apoptosis carried out in recent years and discuss the contribution of these studies to our understanding of poliomyelitis.

Most good judgement comes from experience. Most experience comes from bad judgement.