August 10, 1999,
Tuesday
Health & Fitness
By HOLCOMB B. NOBLE

''On a scale from 1 to 10, how much
pain are you in?'' a laboratory technician asks Bernard Kingsley.
Mr. Kingsley is lying, cramped, inside a huge magnet,
in a space narrow and claustrophobic enough to panic even the brave.
A padded cradle, an antenna wrapped around it, envelops his head.
''Six,'' he signals. Increase the pain , orders one
of the doctors. Mr. Kingsley's legs, stretched out on a flat board,
are raised a bit higher.
''How much now?'' the technician asks.
''Eight,'' indicates Mr. Kingsley.
The magnet emits rhythmical pings. Numbers flash by
on computer screens, as activity in Mr. Kingsley's brain is translated
into pictures at a rate of 40 images per minute. The doctors and
technicians, standing inside a glass-enclosed control room, watch
silently.
''How much now?'' the technician asks again.
''Nine.''
It may sound reminiscent of some sort of medieval
torture session. But in fact, Mr. Kingsley, a 39-year-old former
construction worker, is a volunteer, helping researchers try to
understand how pain works and to find better treatments for patients
like him.
He is one of the first participants in a groundbreaking
new series of studies: lying inside the magnetic resonance imaging
machine at the State University of New York's Health Science Center
in Syracuse, he is having moving pictures made of the pain cells
in his brain.
Until very recently, doctors trying to gauge the severity
of a patient's pain have had to rely largely on what the patient
communicated -- through anything from a wince to a blood-curdling
scream.
But using highly refined diagnostic devices like PET
-- or positron emission tomography -- scanning and functional magnetic
resonance imaging, or f.M.R.I., scientists have been able for the
first time to peer deep into the brain and watch pain at work, ''lighting
up'' specific neurons.
In studies of 14 patients, Dr. A. Vania Apkarian and
a team of neurologists, physicists and technicians at Syracuse have
used f.M.R.I. to locate cell groups in the cerebral cortex that
are activated in response to severe pain in the hand, in various
back muscles and in spinal cord or nerve tissues.
Dr. Apkarian emphasized that it may be several years
before the mountains of computerized data the team has collected
can be analyzed and then used to improve or alter treatment.
But, he said, the early results seem highly promising,
especially when combined with knowledge of brain chemistry gained
during the 1980's and the availability of more effective painkillers.
Other research teams in this country and in Canada
are conducting similar studies. Dr. Karen D. Davis of the University
of Toronto and Toronto Western Hospital and her colleagues, for
example, are using imaging to observe changes that occur in the
brain cells of patients suffering chronic pain after a stroke or
spinal cord injury. They are also investigating the ''phantom''
pain many patients experience after a limb is amputated.
Dr. Howard Field, a neurologist and pain expert at
the University of California at San Francisco, called the work of
Dr. Apkarian, Dr. Davis and others ''a major revolution in medicine.''
The research, he said, is helping dispel a number
of false notions about pain. He said that some doctors, for example,
have believed that it was somehow less worthwhile to devote time
and energy toward lessening a patient's pain than it was to treat
the underlying disease or injury. And as late as the late 80's,
he said, ''the myth persisted that somehow what goes on in the mind,
or the cells of the brain, is somehow less scientific or real than
what goes on physically in the body.''
But the fact that pain, like blood pressure or body
temperature, can now be measured, Dr. Field said, will help convince
doctors that patients' pain is very real. And it may give reassurance
to physicians who treat the most severe chronic pain , like that
of cancer patients. In the past, these doctors have often refrained
from giving enough pain medication to relieve suffering out of fear
that their patients might become ''hooked'' on the painkillers.
Pain experts say that having better ways to measure
pain also will help protect health insurance companies from fraudulent
claims, and help policyholders prove that their claims are legitimate.
The first success in capturing a still image of pain
in the brain was reported in 1991 by a team of researchers in Montreal.
Dr. Jeanne D. Talbot of the University of Montreal and Dr. Catherine
Bushnell of McGill University used PET scanning, which, like f.M.R.I.,
measures blood flow, to watch pain centers of the brain as they
processed messages transmitted by nerve cells at the site of the
injury.
When heat was applied at different intensities to
the arms of eight right-handed male subjects, the researchers found,
four different groups of pain cells ''lit up'' at different intensities.
In PET scanning, a radioactive tracer is injected
into the subject before the scan is taken. When the tracer reaches
the brain, detectors in the scanning machine are able to pick up
positrons -- positive antiparticles of electrons -- emitted by the
substance. The detectors determine where the positrons are located,
and computers translate the data into three-dimensional pictures.
Since the discoveries in Montreal, imaging technology
has steadily improved. Using these new techniques, neurologists,
physicists and physiologists have in effect been given a tour of
pain, as it registers in 200 or more regions of the cerebral cortex.
One of the most immediate uses of the new technology
may be helping identify patients who are are unwilling or afraid
to ask for help.
In a report last month in the Journal of the American
Medical Association, for example, Dr. Kathleen Foley, a pain -control
specialist at the Sloan-Kettering Cancer Center in Manhattan, reported
on the case of ''Mrs. L.,'' a 44-year-old cancer patient she had
treated. Mrs. L., Dr. Foley wrote, understated the amount of pain
she was in because she wanted to remain lucid.
''I haven't really opened my mouth to say I was in
pain,'' Dr. Foley quoted the patient as saying, ''and the trade-off
has been a total fiasco.''
Mrs L. added: ''In my stupidity of wanting to stay
awake, I say that I'm not in pain, and I find out later that makes
it so much more difficult. I want to be awake and know everything
that's going on, for as long as humanly possible. But I do not want
to die in pain . I do not want to be in pain.''
More common, pain experts say, are patients who could
not hide their pain if they wanted to. Dr. Apkarian said the first
patients he studied were suffering from severe hand pain , in each
case caused by some kind of accident. In these patients, he said,
pain recurred long after the wound had healed, and the patients'
hands were often so red and swollen that the nails began to drop
off.
There is certainly no doubt that Mr. Kingsley is in
pain. Approaching the huge, doughnut-shaped M.R.I. machine during
a recent examination at University Hospital, he moved very slowly,
his suffering obvious.
Mr. Kingsley said he is in pain about 70 percent of
the day, every day. When he was 19, one vertebra in the small of
his back started to slip down on another. Doctors told him he had
better stop lifting heavy things and consider changing jobs.
''But I didn't listen,'' he said. ''The lesson from
me is that if somebody tells you not to lift things, don't lift
things.''
Four years ago, when the pain became unbearable, Mr.
Kingsley finally quit his job. Two operations to insert pins in
his back, readjusting the position of the vertebrae, did not help.
And heavy doses of painkillers brought little relief.
Mr. Kingsley's doctors said they are at a loss to
know why he suffers so much. Many other people with the same or
similar conditions do not approach his level of pain, they said.
They suggested that he might want to join the first group of patients
being studied at the Syracuse center.
Inside the laboratory, the M.R.I. machine is sending
radio waves into Mr. Kingsley's brain, while he lies positioned
within the machine's strong magnetic field. The waves interact with
the nuclei of hydrogen atoms in the cerebral cortex, in places where
the pain is registered. The nuclei, in turn, emit their own, smaller
radio signals, detected by the antenna in Mr. Kingsley's headrest,
and translated into images that change slightly as his pain worsens
or lessens.
Sean Huckins, a doctoral student in brain mapping,
instructs Mr. Kingsley to use a set of hand signals to indicate
to the team, watching from the glassed-in control room, the level
of pain he is feeling as the technician raises his legs. After each
trial, he is allowed to rest for a few minutes.
When Mr. Kingsley signals 9 1/2 the trial is halted.
It will take weeks to analyze the data from his trial, Dr. Apkarian
said, but the patterns generated by his brain seem, in preliminary
analysis, to resemble those of the five other back- pain patients
he has examined. They differ markedly, though, from those of six
patients with chronic hand pain and two patients with spinal disorders.
''We've never had brain pictures of chronic pain before,''
Dr. Apkarian said, ''and they show that pain from different types
of causes involved very different areas of the brain. And this seems
to mean they should be treated differently. Just how will have to
be subjected to much more investigation.''
After the session, Mr. Kingsley, clearly exhausted,
says, ''It hurt like hell. But I'm at the point where I'm willing
to try anything.''
''I've run out of options,'' he continues. ''So why
not?''
The doctors have told him that whatever they learn
from the research for which he has volunteered is unlikely to be
of help to him or to others at least for several years.
''But all the patients who are willing and able to
undergo this very difficult ordeal say that if it makes it possible
for other people not to have to go through what they have gone through,
it is worth it,'' Dr. Apkarian said.
Mr. Kingsley falters only once, when he describes
his past life, and how he finally had to quit construction work
when he could no longer stand the pain. Tears come to his eyes.
''I can't even get off the couch now to play with my grandchild,''
he says.
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