WOMEN & PAIN (12/17/19)
As an old fashion doctor who takes time to listen to patients & actually examine them physically, I can report that what women have been telling us about pain is true.
As an old fashion doctor who takes time to listen to patients & actually examine them physically, I can report that what women have been telling us about pain is true.
Women experience more physical pain, more often, & with greater chronicity than men. I would not say they have more intense pain. They just have more pain in general.
I do not believe the female experience is one of lesser inhibition arousing exaggerated complaint of their feelings. What they in fact report is authentic, chronic, & recurrent physical discomfort.
Understanding this issue requires knowledge of tissue pain transducers, a topic seemingly overlooked in debates about the issue. Ligaments of the body are tissues that protect our joints from being pulled asunder. Ligament stretch is quite painful.
Perhaps the fundamental instinct of pain generation & experience is seated in human survival. Pain signals warn of environmental dangers. A grave danger is falling down, fracturing a bone, injuring a major joint, & inability to keep up with the migrating tribe.
The enemy causing humans to stumble & fall is the ambient gravitational field; all about us. Relatively robust muscles & sinews of men protect them from lift & fall injuries. Not so with women who have more delicate body tissues.
Notice all the big structures built by humans: cathedrals, cities, & skyways. Perhaps these are not reflection of job interests so much as evidence that male bodies are more suited to lifting, pushing & pulling heavy objects & falling to the ground.
The anatomical part distinctively differing from men to women are the huge male pelvises compared to female pelvises, which are smaller, more delicate/flexible, & shift generously during ambulation; as most men have observed.
There is reason for these anatomical differences & which are related to survival of the species. Successful birthing & ease of birthing requires a pelvic girdle that is flexible & expandable.
At each menses & during pregnancy, women secrete an hormone, Relaxin, that softened ligaments so that pelvic bones & ligaments of the pelvic girdle are prepared for birthing.
Ligaments are flexible cartilage tissues, but resistant to forces of longitudinal stretch. These ligaments tether joints & protect joints from being pulled apart; reason ligaments are so heavily imbued with pain transducers.
Chinese finger torture of WWll & “The Rack” of Spanish Inquisition fame were so effective at eliciting ligament pain that nearly everyone confessed, as I have been lead to believe; wishing for death rather than intolerable ongoing pain.
Analogously, what torture it must be to experience chronic pain of disease? Perhaps suicide is a self-confessed way to escape constant pain in face of authoritarian refusal to allow doctors & pharmacists to distribute pain medications .
Does not the Constitution promise us “pursuit of happiness”? How can authorities deny this right to happiness & respite from chronic pain. It might be time to return to lawsuits of early 1990’s; as patients sued doctors for not treating their “5th vital sign”
Why do women have more pain? Female hypermobility is common & imparts greater angular rotation of joint ligament capsules & concurrent increased incidence of chronic joint injuries that generate chronic pain.
These are reasons why the medical literature reports that women more easily incur chronic low back pain from menial slip, fall, & pushing injuries. They permanently injure their pelvic girdles pursuing these common activities.
The academic medical literature reports that women can permanently injure their sacroiliac joints (SIJ) as result of menial slip & fall injuries. Women with underlying hypermobility have increased potentiation for these injuries.
IMO, one reason pelvic girdle sacroiliac joint injuries are being commonly overlooked by doctors is that chronic low back pain patterns are indistinguishable as to pelvis vs. lumbar tissue originations & generation.
The diagnosis of SIJ disorder is relatively uncommon in the U.S.; despite academic study announcements that 13-30% of chronic low back pain is generated by ligament injury of sacroiliac joints.
In the U.S., we have ~3x the occurrence of lumbar spine operations as other countries. Poor outcomes, diagnostically called “failed back operations”, seem epidemic. IMO, many of these chronic pain failures follow upon inappropriate diagnosis & incorrect selection for operation.
About 30 years ago a major study, the SPORT trial, was reported in the world’s two most respected medical journals. I seem to remember a Stanford researcher might have been a lead author. It was an interesting study.
Patients with chronic low back pain & deemed worthy of operative procedures were divided into two groups. One group got operated upon. At end of one year both groups were studied & found to be equal as to discomfort levels & disability!
I thought SPORT study would alter approaches to operative lumbar spine procedures in U.S. I don’t have statistics, but my impression is that it has not. My opinion is that not infrequently SIJ disorders are misdiagnosed for lumbar spine disorders.
The U.S. neurosurgical arena seems to be be preoccupied with diagnosis & attempted operative correction of Degenerative Disk Disease ( DDD). Clinical science that DDD is a reliable pain generator is questionable. These are not my original ideas.
Shifting to less controversial issues: Joint pain seem to be a particular female gender hazard. Rheumatoid arthritis & Lupus erythematous arthritis are common, decidedly more common, in females, & both disorders include chronic joint pain, especially of hands.
A few years ago, a medical study of 16,000 women with Rheumatoid Arthritis found that a defining causal factor was exposure to agricultural pesticides. Not surprisingly, this info never made the newspapers. Which gender mostly handles household vegetables?
Recent research discovered female hormones act to remodel ligaments & contribute to penetrance of soft tissue hypermobility (my Thread reader Tweet 12/26/19, “First Study”). This is not genetics gone awry, but rather a dynamic aspect of species survival, i.e., ease of birthing.
This study of estrogens related to altered endogenous cartilage was published: Fede, C. PLoS ONE 14(19):e0223195
More examples of female hypermobility leading to permanent injuries & chronic pain exist: hyperflexible women make great cheerleaders, gymnasts, & ballet dancers; dangerous activities that can generate chronic pain injuries.
Recently, I published (10th Interdisciplinary World Congress on Low Back & Pelvic Pain, Belgium, October 2019; on line) first World announcement of chronic low back pain caused by birth-assisted epidural anesthesia.
At the same Congress, I published a study of the multifactorial causations of Fibromyalgia. In an upcoming thread reader unroll, I am planning to summarize the findings reported in this Fibromyalgia study.
Over last several years, I encountered over ~2 dozen women whose history & physical examinations revealed sacroiliac joint (SIJ) ligament (ligaments hold bone pelvis together) laxity & chronic low back pain following epidural anesthesia during childbirth.
The majority of these women had premonitory soft tissue hypermobility variations, as discovered by in-depth histories and/or physical examinations. In other words, they were potential set-ups for the SIJ ligament injuries they incurred.
Mechanical forces imparted by pushing upper legs back & apart, to widen the birth canal, caused excessive SIJ ligament stretch & permanent ligament injury. The mechanical forces were imparted under directions of the Obstetricians!
The vector of mechanical forces & timing of onset of chronic low back pain in this cohort of epidural-related SIJ ligament injuries followed upon invitation of friends & relatives into delivery rooms to do the leg “pushing”.
In the course of history taking it was interesting to note that, nearly universally, the women had long considered that epidural needles had damaged their back tissues. They were wrong.
While under influence of anesthesia & loss of compensatory reflexive splinting & guarding against excessive ligament stretch, these women incurred torn & chronically pained SIJ ligaments which never regained tethering strength.
The chronic low back pain these women now harbor is iatrogenic (caused by medical providers) & a direct result of vectors of mechanical forces imposed upon their pelvises when they were vulnerable to injury.
The direction of mechanical forces during the leg pushing activities were the exact force vectors that leverage the pelvis & exert rotational forces upon ligaments of the SIJ’s.
It is no coincidence that painful conditions of Fibromyalgia, CRPS, TOS, TMJ, Chronic Cervicalgia, Migraine, & Dysautonomias like IBS & IC afflict women significantly more than men.
My series of essays about these chronic pain disorders are among my Twitter posts, & within each essay I have delineated how soft tissue hypermobility predisposes to evolution of each of these chronic pain disorders.
Female genes favor hypermobility, which is associated with these chronic pain disorders. What is being referenced here are no insignificant numbers. Painful Fibromyalgia afflicts ~4% of humans, mostly women.
The incidence of Fibromyalgia is trans-cultural (occurs with equal prevalence in all race types) showing that it is a fundamental human trait & not a cultural function nor behavioral phenomenon.
“Endometriosis” is a label given to a chronic pain syndrome that is estimated to afflict 1:10 women. Over time serial laparoscopic exams are common within this population of chronic pelvic pain sufferers.
Reliable academic clinical medical reports inform us that painful intestinal adhesions follow upon most abdominal & pelvic invasive procedures in women.
Could “Endometriosis” pain reflect iatrogenic IBS caused by kinked & inflated partially-obstructed bowel; with stretched bowel wall smooth muscle tissues beset with activated mast cells?
Recent medical literature reports that hypermobile tissues are hotbeds of mast cell activation, which is directly effected & exacerbated by stretched nerves contained within these hypermobile tissues (Wang, 2010).
Other researchers have shown that stretch of the extracellular matrix induces mast cell activation (Fowlkes et al, 2013).
Other recent medical literature reports that female hormones induce soft tissue hypermobility (see my Tweet of 12/16/19, “First Study”. Female tissues are targets for hypermobility of soft tissues & consequences are intense manifestations of painful Ehlers-Danlos Syndrome.
Recent clinical reports are that Ehlers-Danlos prevalence is 1:500. My own studies of prevalence of Hypermobility & related chronic pain syndromes indicate that prevalence is more frequent than this (my Thread reader unroll, “PREVALENCE OF HSD”, 11/10/19).
Pain meters are a long way from being invented. The best pain meter in all of medicine is the patient’s own body. Doctors need to listen to patients’ pain complaints, make efforts to discover pain generators & rationally treat hyper-arousal of these generators.
If opiate analgesia provides pain relief enabling therapeutic physical therapy, which academics have agreed is appropriate & healing for CRPS, then authoritarian bureaucratic efforts to obstruct effective physical therapy is thoughtless & inhumane.
These bureaucratic BNDD & CDC decisions are not legislative “constitutional” law. They are what is officially called “underground” (an official terminology) or “administrative” law.
What the public does not generally understand is that after constitutional legislative law is passed in congressional bodies, then administrators are allowed to implement the law as they see fit. This is inception of “administrative law”.
Some of the current (national investigative revelations in the fall season of 2019) egregious illegal efforts of a major federal department are glaring examples of this process run amuck.
Egregious violations of human rights by means of perverted administrative laws abridge our Constitutional rights to life, liberty, & pursuit of happiness.
The Constitution provides that the most effective way for people to reverse administrative law is to protest, but not with force or violent demonstrations, but via the Courts.
Simply stated, if patients believe that administrative laws are interfering with their right to have opiate analgesia for unremitting chronic pain, they need to seek legal redress by approaching the Court. Period.
I am neither a woman, an activist, nor experiencing chronic pain. Otherwise, I might organize a “Women Day Of Rest”. On this day all women would stay home & tend to their pains.
(Somewhat tongue-in-cheek) On the “Women Day Of Rest”, participants would stay home & spend quality time tending their outdoor Cannabis gardens. Surprisingly, as opiate bowdlerization waxes anti-Cannabis prohibition wanes.
Ut Oh!! There goes another handful of Twitter followers. Happens every time I mention the evil weed. Less people to block is a small relief, I guess?
Reason for the growing popularity of Cannabis is that it works; as 10’s of 1,000’s of academic reports in the world medical literature (except U.S. of course; where research for efficacy is relatively frowned upon) reveal each year around the globe.
A few years ago, when I was more active in Court appearances in defense of Cannabis users (I have studied the endogenous endocannabinoid system; something frowned upon in most U.S. medical schools), I did a study of the opiate efficacy of Cannabis.
I studied a group of busted-up (mechanical injuries) mature men. What I found, by detailed history taking, was that their current use of cold-water hashish (non-decarboxylated, non-heated, to minimize the “high”) mostly eaten.
Since 2003, hashish extracted by natural means, not with butane, has been legal in CA. Butane is a dangerous extractant that leaves cancer causing residues; despite what high school garage scientists pontificate about the matter.
These men who I studied had formerly used prescribed opiates for their chronic pain. Being expert in opiates for pain (17 years doing Industrial Medicine; 1990’s & 2000’s), I knew how to collect opiate data & convert to mg of Morphine equivalents.
What I discovered, in what is arguably the first study & report of this nature, is that 1 gram of hashish extracted with water & sieves was equi-analgesic to 30 milligram of Morphine (three 10 mg Norco tablets).
I was careful to keep this publication off the public radar; with concern for becoming the go-to Cannabis doctor. Rather, I published in numerous Court hearings & into Court testimony & entered the paper into evidence.
My selectivity of publication kept an hoard of Cannabis certificate seekers & undercover investigators from my office door, but brought me law enforcement persecution in other ways. But that is another story, a noble one.
Another phenomenon observed while encountering thousands of Cannabis users in a clinical practice setting was the therapeutic efficacy of topical Cannabis alcohol or oil based lineaments & salves.
Most patient revelations about the benefits of topical Cannabis were provided by patients in an unsolicited fashion. They used it for joint pains, muscle spasms, & myalgias.
For years I contemplated how the cannabinoids might cross into deep soft tissues, to levels of fascia, muscles tendons, & ligaments. Physicians have historically regarded skin to be a barrier against the outside world. But this concept is changing.
As I contemplated skin absorption of cannabinoids, it occurred to me that each hair follicle has a sebaceous gland that provides fatty lubricants & anti-bacterial oils to the skin.
Walla! These sebaceous glands and their tiny oil ducts were miniature “I.V.’s”, so to speak, delivering fat-soluble pain-diminishing cannabinoids into the subcutaneous tissues.
My idea was then to recommend a warm shower prior to topical application or an heating pad over the region after topical application & to open the pores. The topicals worked even better.
I know that Cannabis topicals work because many more people recommended it than those who disavowed efficacy of topical Cannabis. I do not require a placebo controlled random trial with english-speaking rats to confirm my understanding.
Empirical observations were mainstay of clinical advancement for ~5,000 years of clinical medicine; until about 100 years ago when German doctors & Merck Pharmaceuticals cornered the clinical data collection market.
Most doctors are wise enough to sort out people with authentic pain from the phonies; who eventually reveal themselves even if they are exceptional at theatrics.
If doctors only learned how to make the diagnosis of chronic soft tissue pain generators, they would not feel so insecure within the clinic arena as relates to understanding & treating chronic pain.
No one is advocating that just because a person says they have pain they should received pain medication. They have to be proven to have a need. Pain relief is a rational way to handle chronic pain. Pain free survival is better than no survival at all.
The problem is that doctors are not trained to ferret out pain generators. If something does not show up in blood test or X-ray, doctors are commonly at loss how to gather signs, symptoms, & diagnosis of a chronic pain disorder.
When doctors are unable to deduce diagnostic etiology from the mechanism of injury, symptoms, & examination, they are then absent justification for prescribing analgesic medications.
These elements, history & physical examination, are taught to doctors in medical school anatomy, physiology & psychiatry, but no courses are offered to tie all of these elements into a global method of pain diagnosis. It took me decades to teach myself this skill.
Recently, Dr. S. Mackey, a Professor and leading pain researcher at Stanford Medical School, reported that the average pain management coursework in American Medical Schools is 11 hours (22 hours in Canada)!
Ladies & gentlemen if you ever wanted to know what is perhaps the major reasons we have a crisis in pain management in the U.S. you now know it, and you heard it right from the horse’s mouth.
I wrote a thread reader unrolled in response to Dr. Mackey’s observation (he made 11/16/19). It is too expansive to summarize here. My essay was posted on 12/19/19 as “PAIN TRAINING”.
Methods I discovered as to chronic pain diagnosis are being incorporated into 2 books I am currently finishing while in battle with villains that protest these efforts - time & money.
Name I have chosen & trademarked for these methods of chronic pain syndrome diagnosis is, “Biomechanical Functional Diagnosis”. The premier Syndrome I discuses is Fibromyalgia-The Super-Syndrome.
Fibromyalgia a Super-Syndrome? Yes. To know Fibromyalgia, one must understand Migraine, TMJ, TOS, POTS, Gastroparesis, Low Back Pain, Sciatic, IC, IBS, CRPS, Chronic Fatigue, & several Dysautonomias. HSD & hEDS are similar medical arenas wherein to parry with Chronic Pain.
In truth, even if doctors knew how to diagnose chronic soft tissue pain generation, they do not have time within the current medical marketplace. Time is needed for in-depth history & physical examinations to make proper diagnoses. It is a sad state of affairs.
When it comes to opiate analgesia, doctors are being taught that they have to keep people from becoming “dependent and addicted”. It is good that doctors understand the difference.
If only editors at Time Magazine would learn to distinguish these 2 medical terms. One of the problems within the national conversation about opiates is global ignorance about the clinical phenomenon of “addiction”.
When it comes to development of dependency, a 2 week course of Norco/Vicodin is all it takes. Most people have minimal difficulty stopping lower levels of opiate use, & if tapering is undertaken the majority have no great difficulty; except for ~15% (see below).
Being dependent not a bad thing. It is not participating in sociopathic acts to satisfy psychologic cravings (definition of “addiction”). Dependent people find level of usage/comfort & stay there. Idea that opiates create an uncontrolled & ever escalating hunger is Hollywood myth
People become dependent on lots of things. It is a physiological reward system phenomenon. Stimulation of brain opiate mu receptors feels good. So does brain dopamine release in response to foods, gambling, & gaming.
A reward is a reward is a reward. If a person shows signs, which doctors are expert at recognizing, of transiting to addiction then opiates need to be tapered & withdrawn. Cannabis & Kratom are possible replacements.
It is now firm science that Cannabis is neither a gateway drug nor addicting; no matter what ignorant office-seeking politicians may pontificate.
Most people (~85%) do not shift from dependency to addiction. It seems to be a genetic thing. But 85% should not suffer because of the genetically challenged 15%.
Freedoms to pursue happiness are Constitutional rights. How does the government get to usurp rights & prohibit doctors from relieving people’s chronic pain? (see diatribe above about constitutional law from this kitchen table lawyer, me)
There needs to be some legal activities to assert constitutional rights when it comes to pain relief. Maybe we need to reinvent some of the court cases that manifested in the 1990’s, when pain became the 5th vital sign, & doctors were being sued for not treating pain.
There are physician pain experts who could help make the case for opiate analgesia. Unfortunately, threats of license revocation has dampened enthusiasm of most doctors within the arena of opiate pain management.
Prominent academic pain clinicians have become inarticulate bystanders to the national conversation. Perhaps federal policy & grant monies have muted these types of academic research conversations. Listening Stanford?
Men making laws about opiate use for chronic pain experienced by women is an oxymoron. Any national committee intended to reposition national policy about these matters should include at least 50% women in committee compositions.
Another action to advance the national conversation is to keep Psychiatrists who do not take care of chronic pain patients out of the conversation, & to stop featuring them as “experts” in congressional hearings.
The national conversation needs to be led by physicians who are on the front lines & in the trenches of the War Against Chronic Pain. But first, they must be given immunity for their testimony & opinions. Otherwise they will be marched off into the opiate gulag.
IN CONCLUSION: women suffer plenty of chronic pain. Perhaps they are the group who should organize to take back their natural rights to use nature’s medicine cabinet, Opium & Cannabis extracts, for their suffering & in search of happiness.
@threadreaderapp unroll please.
