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Welcome Readers and Partners in Care

Welcome friends.

I hope you find this site helpful. I have created it to help you manage chronic pain or anxiety and stress. Please remember to heed your healthcare provider’s advice first before following my advice.

Good Luck. Judy

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Diabetes in Covid-19 times

Good morning dear readers

This morning I would like to urge any readers to pass news along to their relatives with diabetes that they need to be particularly careful in these difficult times. 

COVID-19 has caused universal stress and stress raises glucose. In Canada we have a help-line 1800 BANTING (18002268464) where a person can speak to a diabetes educator. There is also a Diabetes Prevention Program that can be accessed. 

I have also added education on diabetes on my site on this link – Diabetes. There is a video on foot examination and other education videos. 

Stay safe everyone. If you have symptoms you are concerned about, contact your health care provider. 

All the best

Judy

 

 

Resources for First Nations in BC

There are new virtual resources available for First Nations people in BC.

Substance Use and Psychiatry Services

Referral Guide for Physicians

Doctor of the Day

Instructions for Virtual Care

Wishing you well. Take care

Judy

Alberta Pain Conference 2020 – More on Migraines

Notes taken while attending. Please contact me to advise on errors. Thank you

Dr. Werner Becker: Migraine needs a complex and comprehensive treatment trial.

He organized CHAMP headache program.

He emphasized that avoiding Codeine is important. Tryptans have replaced Ergotamine. Eletriptan and Rizatriptan are good examples, and injectable Sumatriptan, nasal Zolmitriptan.

The future is here – south of Canada’s border. The Gepantsa and Lasmiditan that doesn’t cause vasoconstriction, although it causes sleepiness and dizziness, and may cause driving impairment. Of note, the benefit is still to be discovered. In some studies it helps about 20% compared to 10% helped with placebo.

Dr. Lara Cooke spoke about when is a headache not just a headache. She gave us fabulous Pearls.

Migraine is a primary headache because it is not caused by something else, like a tumor. Usually it’s longer than 4 hours. It is usually one one side, pulses or throbs, usually is moderately to severely painful, it can be made worse by activity. It often comes with nausea or vomiting or light sensitivity or sound. Only 20-30% of people will have auras.

Look for red flags – then may need imaging. Examples of secondary headaches include caffeine withdrawal and a post-concussion headache. Thunderclap and new daily headaches need to be investigated.

Cluster headaches are so bad they are called suicide headaches. An awful pain. I have seen these patients in my office, thank goodness not for a while. Injectable Sumatriptan can work. I have used high dose oxygen – luckily our ER is close by and costs the patient zilch. zero. nada. Got love Canada. Can’t help bragging.

SUNCT – short acting unilateral neuralgiform headache with conjunctival injection and tearing. Certain anticonvulsant medications can work. They can be associated with pituitary lesions.

Look for red flags for another cause – like headaches getting worse over time. Short lasting headaches can be from a tumor in the posterior fossa.

SNOOP4: Systemic symptoms, signs, disease, Neurologic symptoms or signs – like vision or auditory symptoms, Onset sudden, like a thunderclap, Older onset, Papilledema, Positional symptoms from changes to intracranial pressure- worse lying or standing, Precipitated by Valsalva. and if Progressive. Ask – what do you do if you have this headache.

I would also like to remind professionals to think about temporal arteritis. A simple CRP in a suspicious case can save a person’s vision.

Dr. Michael Knash focused on the clinical side of headaches and migraines. 3 Billion people have some kind of headache disorder. He reminded us that headache in pregnancy could be associated with a clot.

He reinforced acute and preventative measures for chronic migraine and how socioeconomic factors can influence migraine management. He did mention the very real risk of death associated with use of opioids over 200mg equivalent Morphine.

Canada is still waiting for approval of many drugs. I don’t mind the wait. I appreciate the need for caution. Erenumab is now available (CGRP Mabs). Also mentioned the use of Botulintoxin and Topiramate.

Such a great way to spend a Saturday.

Thank you all

Judy

More on migraine and headache – Alberta Pain Conference

Dr. William Kingston presented the Conundrum of Managing Migraine with Comorbidities.

More than 10% of people in Canada have had migraines. (I’ve had migraines when I was premenopausal and they were so painful it started my journey to healing and drove me to help my patients manage their own pain). We must not forget the stress of pregnancy and postpartum depression. Hormones and other factors are a huge load on women.

There are groups with migraines who have metabolic problems, diseases like diabetes, hypertension, dyslipidemia, hypothyroidism. There were also groups of people who suffered from anxiety, fibromyalgia, and depression. There was another group who had no co-morbities.

Choosing medications to manage migraine can be incorporated in the medications used to treat conditions like hypertension. There are safer pain medications to choose from when looking at complex patients.

He mentioned prochlorperazine for patients with resistant migraine and Gabapentin.

He spoke about the vicious cycle that results when patients suffer from migraine and depression – two separate but intersecting conditions. Treating migraine can improve your mood. Depression can often present without the typical low mood. There are other presentations of depression. Venlafaxine could be a good drug to try.

Cognitive behaviour therapy can be helpful – Kelty provides free online CBT. Other On-line resources.

PTSD is also important to address if this is present.

When everything does nothing, there may be something – I think searching for hidden trauma, hidden stress, is worthwhile. Step 1 – Rate your pain has links to forms assessing for depression or high adverse child events. Please check in with yourself for hidden triggers and consult your health care professional.

Have a great day

Judy

Alberta Pain Conference 2020 – Migraine Treatment

Dr. David Dodick gave an excellent presentation about a new approach to migraine therapy. He explained the biology of pain so that we reduce the stigma of migraine and provide more effective medications with less vascular side effects. This disease is complex and demands a complex treatment approach.

Here is a good link I think to the new type of therapy. CGRP – A new era for migraine treatment.

If usual therapy has failed in managing migraines, these new medications could be a good option to treat migraines.

He also discussed the research in the role of PACAP in migraine. Perhaps we are now looking finally at effective management of trigeminal neuralgia? Research underway.

Dr. Becker says it takes more than a molecule to treat migraine. I am looking forward to his talk later on.

Judy

Alberta Pain Conference 2020 Pain Research Networks

I have summarized the wonderful talk by Dr. Norm Buckley. Please call me on any misrepresentations so I can correct them.

Dr. Norm Buckley introduced the partners in the Chronic Pain Network and the work they are doing. It is the first research network dedicated to pain in Canada. Speaking about the opioid crisis, he says, “We realize we missed the boat”. So refreshing – Health Canada approaching the opioid health crisis differently.

It is the first time the government is recognizing pain as a priority, starting the Canadian Pain Task Force.

First time CIHR has really invested in pain research. $12.5million over 5 years plus matching funds of $24million.

A dedicated group of researchers trying to grapple the very difficult problem of chronic pain in a setting of millions of patients suffering from undertreatment of pain.

Veterans face a significant problem related to their service. They have established a life after service study. Veterans have worse health on average than other Canadians. They have worse pain. 50% of female veterans have chronic pain.

They have 3 research institutions that are working to reduce the impact of military service on health. They are even researching Cannabis – Veteran’s Canada reimburses the use of cannabis for veterans. Also PTSD and chronic pain. Measuring 7 key measures of well-being. Intergenerational – transgenerational impact of pain.

Patients are being heard! Pain has become a priority. Very Exciting. Hooray Canada!

Judy

Alberta Pain Conference 2020 – what’s new in pain

Dr. Tasha Stanton – targeting pain from many angles and the importance of language, sensory modulation, and brain trickery.

Dr. Stanton also mentioned the complexity of the Flight Fright Freeze response.

The context of your environment contributes to pain – measuring the nociceptive withdrawal response/reflex can tell us about the level of threat and how pain is affected. We have a dynamic system that updates based on available information for that person, in that environment, in that society. The balance of information, these cues affect pain.

Research with laser zaps and different stimuli show very interesting results. A person smelling a soothing smell will experience less pain than the person immersed in a toxic smell, like a fart.

Words can alter the pain experience. If we hear words with danger cues, then pain increases. What we are told about our body influences pain. (Reminds me of how easily a doctor can cause a side effect with the choice of their words).

Things hurt more when they aren’t sure they are safe. Every clinical encounter is an opportunity to add or decrease the danger response. Be careful about the message you give a patient when you, as a clinician, report on things like X-rays. For instance, there are so many people with osteoarthritis who have no pain. (Same with MRI’s of the back). Imaging doesn’t determine your outcome. Doesn’t always correlate with pain levels.

Imbue safety cues rather than danger cues. We are BIOPLASTIC – love that.

Your body continues to adapt even you are ageing.

Exercise is so important. Do not give danger cues that movement is bad. Evidence supports that movement can hurt initially, but then will get better. Tissue adapts through loading. Slowly increase your effort. Check out the links Pacing and Gentle Exercise which is important in managing chronic pain.

Also look at how you speak about your own body, even when it’s what you say about yourself. Don’t talk about your “bad” body.

She shared research that proved information from one sensor can change the pain experience. It even causes physical changes, like reduction in the swelling of the knee. What you see can change what you feel. You can change your perception by looking at something differently – your brain accepting that change can occur through strong sensory input.

Increasing your confidence, perceived strength, and decreasing fear, all lead to decreases in pain intensity. How well you feel your body is equipped to do tasks influences your pain and function.

She shared fascinating research sharing illusions used to decrease a burning mouth by using colour to create the illusion of pain reduction. Using mediated reality, they use mirrors to flip a patient’s reality to work on patients with phantom limb pain. Moving the remaining limb in the mirror can feel as if the phantom limb is moving and can reduce pain.

Sound information has strong links to feeling and movement. Stiff joints make a lot of noise. They did research pairing sound with pressure on their back. Using loud awful noise, the patient’s pain increased. When the sound was soothing and whooshing, the pain was less.

You can look up studies on The influence of auditory cues on bodily and movement perception.

Using brain trickery can be used to help pain. Priming the brain can shape your expectations. Effective priming can influence what we can achieve.

If we understand these influencers of pain, we can change the way people experience pain. Our words matter.

Thank you

Judy

Alberta Pain Conference 2020 Cannabis

Dr. Hance Clarke: Science is struggling to catch up to clinical use of cannabis. We are interested in cannabis when we look at any neurodegenerative disease.

Hooray Canada – second country in the world to legalize cannabis. (I believe if alcohol is legal, then cannabis should also be.) During Covid, Canada tried to make sure that people had cannabis. Reports show that 16% were using cannabis for pain and at least 22% had tried it.

There are protocols for use of cannabis. Dr. Clarke introduced guidance using cannabis, particularly involving perioperative use.

CBD vs Cannabis. More than 10:1 is CBD driven vs THC driven. The increased use of THC increases the use of side effects. Greater than 1.5g of THC is worrisome. More than 300mg of CBD is also worrisome. Be careful about unregistered products – more than 2 to 3 per day should be avoided.

He introduced experts linked to CCT Cannabinoid Therapeutics and the RWE Clinical Trial. The products used in the trial are expertly checked and analysed. MCRWE.ca

Real world evidence coming out. Check out Alberta innovates.

Judy

Alberta Pain Conference 2020

Hi Readers

Dr. John. Pereira: A healthy diet is especially important if you live with chronic pain. Food is the source of home improvement.

Inflammation is a key part of the stress response. It turns on in response to stress. In this conference I have heard the word inflammation mentioned many times, including in discussions about dementia. In the 21st Century – we have many activators of inflammation. Just turning on the news is enough to become inflamed. Poor sleep. Too little or too much activity. Too little relaxation. All contribute to inflammation.

He speaks about diet. The importance of avoiding processed foods. Consuming omega oils in fish low in mercury. He talks about the importance of avoiding free sugar – this includes sugars added to foods, including honey. Natural healthy foods reduce inflammation. Eat across the colour spectrum. Turmeric contains curcumin and may reduce inflammation. But it can affect gall bladder disease and cause thinning of your blood. Garlic also reduces inflammation and thins the blood.

Talk to your healthcare provider before you make any changes. Check out Diet, Lifestyle, and Chronic Disease. I do love the recipe he shared – shrimp and garlic cooked in olive oil over medium heat, with sundried tomato, basil, and oregano.

Thank you John

Have a great day all. Judy

Alberta Pain Conference – Pediatric Pain

Hi Bloggers

Today and for the rest of the weekend I am attending the Alberta Pain Conference. How wonderful that over 4000 people from all over the world joined in to learn and help fight the battle of chronic pain. Even more so that the conference includes people who suffer from chronic pain – our best teachers. I have made some notes of the meeting so far. Apologies to the presenters if I misrepresented you in any way. Please call me on it so I can correct it if I do.

Thank you Katie for sharing your journey. Reminding us how important it is to listen to the patient’s experience of pain. Reminding us of how chronic pain comes with grief – the loss of your function; the loss of the vision you have of yourself; sometimes the loss of the future you imagined for yourself.

Thank you for reminding us that small daily goals work, that you need to choose your own activities – pursue your own interests, and find things that you feel you can do. Be kind to yourself if you can’t do everything you want. Find a community of other youth who suffer from chronic pain. Thank you for sharing your courage and hope.

Dr. Katie Birnie reminded us of the importance of the patient and the family in the partnership of care. Invest in research that is important to Patients! Mutual respect and inclusiveness in the most important part of care. She also spoke about her research – a multidisciplinary team approach to research.

The gaps identified include attention to sleep, physical interventions, patient satisfaction, and adverse events. Some shockers – 2/3 of children continue to have procedures without adequate or any analgesia. Vets gets 75% more pain education than medical professionals. It takes 17 years before research reaches the people who should see the results. I think it takes even longer to introduce the changes needed. She introduced SKIP and invited us to visit Kidsinpain.ca.

Dr. Melanie Noel tells us 1 in 4 children suffer from chronic pain, pain like migraines and stomach aches. Even if the pain resolves, these children are at risk for lifelong consequences, including PTSD, anxiety, and depression. Distressing memories can affect us for life.

She studied chronic pain and the link to trauma. How does your mother, or your father’s trauma affect you, as a child? Can trauma be carried through your genes? Her research backs the rational truth that past traumas, like high ACEs, affect the development of chronic pain and how you respond to treatment for pain.

She speaks about the importance of sleep and how sleep deprivation can affect mood and pain – even 30 minutes less sleep than necessary is a risk factor, especially in adolescents. Poor sleep drives pain and pain causes poor sleep. A vicious cycle. Children can benefit from cognitive behavioural therapy.

Go to bed when you are really tired. Don’t lie in bed if you can’t fall asleep. If you wake up and not sleeping after 15 minutes, get up, break the association of the bed with not sleeping. DO NOT GO ON YOUR PHONE. Do something calming or boring (ha ha – read a dictionary).

The tragedy is that most children often don’t access any, or adequate, medical assessment. Most children with chronic pain have parents who have experienced chronic pain. Treatment of parents, acceptance of the needs of parents too, is vital when we treat children with chronic pain.

She did give us hope – positive message – positive childhood experiences can buffer the effects of abuse in childhood. Children are resilient and can be protected. Protections: The ability to talk to your family about your feelings, enjoying community experiences, support by friends or another family member, and a feeling of safety.

Dr. Samina Ali. children who have procedures who have poorly managed pain have longer healing periods, they stay in hospital longer, they can have enduring fear and anxiety over future health care, like needlestick anxiety, and they can even avoid going to a health care professional when they are older.

It was horrifying to listen to her research – how children had major surgeries – heart and abdominal surgery, children with severe pain – how they never received pain medications. White children were twice as likely to receive necessary opioids than black children. We have work to do on ALL fronts.

Managing pain in children, physical measures matter, even something as simple as a warm blanket, a warm hug,; psychological – nowadays we can even use virtual distractions, or a book, or an iPad, or something as simple as bubbles; pharmacologic tools should be used, included opioids when needed. Mild to moderate can be treated with Ibuprofen (10mg/kg) and Acetaminophen (15 – 20mg/kg) and both these drugs decrease the need for opioids and will decrease the dose needed. DO NOT USE CODEINE. DO NOT START CODEINE. (Might consider continuing use in an adolescent who has already found relief).

If you use opioids, sent patient home with modest amounts of opioids. Short-term treatment is most important – usually 3 days of treatment. Give the patient a back-up plan in case they struggle with their pain.

CAPHC online resource available to anyone in the world.

On average, a child admitted to hospital has to suffer 6 painful procedures. Only 28% have adequate pain care. Up to 80% of emergency care visits are pain related. More than half of all procedures were done with no analgesia. No intravenous procedures without analgesia.

We need to use topical anesthetic. Comfort positioning. Distraction. Analgesia.

We can do better! Dr. Nivez Rasic: All chronic pain was at one time acute.

Dr. Rob Tanguay says you can’t treat chronic pain without looking at trauma.

Thank you for a wonderful talk by experienced, knowledgeable, caring people.

Judy