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gt;gt;Overall, more than 70,000 people ended up with a shoveling-related injury bad enough to trigger a doctor’s visit in 2008, according to the Consumer Products Safety Commission. A quarter of those people visited an emergency room, and about 900 were admitted to a hospital.gt;gt;The exertion, cold weather, and slippery surfaces snow shovelers face are a dangerous combination, especially if it’s an activity you’re not used to. Snow shoveling "is one of the most high-intensity exercises you can do," says Suzanne Steinbaum, DO, a preventive cardiologist at Lenox Hill Hospital, in New York City. "You’re using all your major muscle groups."gt;gt;But there are steps you can take to shovel safely and ensure that you survive the winter in one piece.gt;gt; gt;Back paingt;gt;The number-one injury sustained after a snowstorm is lower back strain, according to Henry Goitz, MD, an orthopedic surgeon at Henry Ford Hospital, in Detroit, and a spokesman for the American Academy of Orthopaedic Surgeons (AAOS). "That’s when a muscle gets over-tensioned and tightens," he explains. "If it over-tightens, it’s almost like a spasm and that gets very painful."gt;gt;Another common back injury incurred during shoveling is a gt;herniated diskgt;, says Victor Khabie, MD, the co-chief of orthopedic surgery at Northern Westchester Hospital, in Mt. Kisco, N.Y. A herniated disk (also known as a slipped disk) is when one of the soft disks between the vertebrae comes out of position and pushes on a nerve.gt;gt;If your post-shoveling recovery includes back pain that radiates down your leg, it’s a bad sign. "That may mean you have ruptured or herniated a disk," Dr. Khabie says.gt;gt; gt; gt;The combination of frigid weather and normally sedentary people going all-out can be a recipe for back injuries. "The shoveling tends to be done by people who are not otherwise in good shape," says Richard Pomerantz, MD, a professor of medicine in cardiology at the University of Rochester Medical Center, in Rochester, N.Y. "Sometimes a potato chip is the heaviest thing they’ve lifted for a while."gt;gt;The snow is not the only danger. Ice lurking underneath snow can potentially cause even worse injuries. Evalina L. Burger, MD, a vice chair and associate professor of orthopedics at the University of Colorado, in Denver, says she has seen no acute injuries from shoveling over the past three years but "horrible injuries from slipping on ice, including bad fractures."gt;gt;"The worst thing is a fall," she says. "It’s not just old people who fall."gt;gt; gt;Heart attacksgt;gt;Though rare, heart attacks that occur while shoveling snow have a long-standing place in medical lore—much like gt;heart attacks that occur during sexgt;.gt;gt;In the late 1970s, researchers from the Centers for Disease Control and Prevention studied six major snowstorms in Massachusetts (including the record-setting Blizzard of ‘78), and found that heart disease-related deaths rose by 22% in the week following a storm. Men were responsible for the majority of the spike, which "might be explained by snow shoveling," the researchers noted.gt;gt;The combination of exertion and cold weather are believed to be the cause of shoveling-related heart attacks. "We don’t like heart patients doing tons of heavy weight lifting coupled with cold weather," says Dr. Pomerantz, whose home of Rochester averages about 7 feet 8 inches of snow each year.gt;gt;There’s both an aerobic and weight lifting component to snow shoveling, says Dr. Pomerantz, and the weight lifting portion can raise blood pressure. "You’re increasing the load on the heart very, very quickly when maybe the heart is not used to it," he says. "If you do that in a setting where it’s cold, your arteries and vessels tend to constrict, so the relative blood supply goes down at a time when you’re asking the heart to do a lot more. Demand is high and supply is low and that can be too much sometimes."gt;gt;Moreover, hormones released during cold weather and exercise can cause gt;plaquesgt;—fatty deposits that line artery walls—to rupture, leading to blood clots and gt;heart attacksgt;. "If you have plaque in your arteries, this is a perfect time for them to rupture and lead to a heart attack," Dr. Steinbaum says.gt;gt;Timing may also be a factor. According to a 1996 study in the , many people shovel in the early morning, when the gt;risk for heart attacks is highergt;.gt;gt;gt; gt;To avoid injury, shovelers should follow a few simple rules:gt;gt;• gt;Stay in shape.gt; People who are in shape year-round have less to worry about when the flakes start falling.gt;gt; • gt;Work up to it.gt; Warm up inside, and incorporate gt;stretchesgt; (especially gt;for the hamstringsgt;) as well as gt;core-strengthening exercisesgt; such as mini sit-ups, crunches, or working an exercise ball.gt;gt; • gt;Don’t try to do it all at once.gt; Shovel small amounts of snow at a time, especially if the snow is heavy and water-laden. "If you’re not used to exercising or you’ve had a back problem in the past, the smart way of approaching this is to do a little bit at a time," says Dr. Khabie. Shovel for 5 or 10 minutes, then go back inside for 10 minutes to do more stretching.gt;gt; • gt;Practice proper technique.gt; The AAOS advises pushing the snow-containing shovel instead of lifting it. But if you do have to lift, "do more of a knee squat, your back arched as if looking to the sky," Dr. Goitz advises. Don’t bend from your waist. When disposing of the snow, keep the shovel close to your body and, again, squat with your legs, Dr. Goitz says. Walk over to where you’re going to dump the snow, as opposed to leaning over and throwing it. By no means should you rotate or twist your body. "That’s the worst thing you can do for your back in general," says Dr. Burger. "That’s how you herniate disks."gt;gt; • gt;Pick the right tools.gt; Ergonomic shovels "tend to take the stress off the back," Dr. Khabie says. Adds Dr. Burger, "The bent handle gives you a better angle. You don’t have to go down so far and you don’t have to go all the way back up."gt;gt; • gt;Layer warm clothing.gt; Being underdressed will leave you vulnerable to a painful strain. "You don’t want to go out there and really freeze because it will tighten up your muscles," Dr. Khabie says.gt;gt; • gt;Wear snow boots with good traction.gt; "If your feet slip, it throws off your entire balance," Dr. Khabie says. "Find a good, sturdy snow boot that’s made to be out in the snow." Consider keeping a set of spikes in your car, Dr. Burger adds. "They take two minutes to put on—versus six weeks off from work if you injure yourself."gt;gt; The cardinal rule is to practice a bit of common sense. As with any exercise, if you’re out of shape, have had back injuries in the past, or have a history of gt;heart diseasegt;, check with your doctor before tackling that snowdrift. This is wise even if you don’t have heart problems but have high blood pressure or gt;diabetesgt;, or are overweight—all of which are risk factors for heart disease.gt;gt;For some people, the safest thing to do might be to outsource the job to a son, daughter, or neighborhood teenager who’s looking to earn a little pocket money. ]]> Getty Images

gt;gt;It's a clever dig—because, well, it's impossible to prove. But in fact, lab experiments suggest that women are more—not less—sensitive to pain than men.gt;gt;"Contrary to popular opinion, it is very clear that women have a lower pain threshold and tolerance than men," says Roger Fillingim, PhD, a pain expert and professor of community dentistry and behavioral science at the University of Florida, in Gainesville. When study volunteers are exposed to an increasingly painful stimulus (such as a heat source) in experiments, Fillingim says, "women say 'stop' sooner."gt;gt;This may explain in part why gt;chronic paingt; conditions such as gt;arthritisgt; and gt;migrainegt; are more common among women, in some cases dramatically so. gt;Fibromyalgiagt;—a chronic condition marked by widespread pain, as well as fatigue and other symptoms—affects seven times as many women as men, for instance.gt;gt;Exactly why women feel pain more intensely—and in higher numbers—than men remains a mystery. It's not simply that women aren't as "tough." Pain is a complex phenomenon, and how a person responds to it involves physical, psychological, and even cultural factors.gt;gt;"Women experience more pain then men," Fillingim says. "We know a lot of different whys, but we don't have a single answer."gt;gt;Questions remain, but the female body and mind do appear to process pain differently than a man's. And these differences can affect every aspect of pain, from the physical sensation itself to how women cope with chronic pain and what treatments are likely to be most effective for them.gt;gt;gt;Different bodies, different paingt;gt;Sex hormones may be responsible for much of the difference in how women and men experience pain, experts say.gt;gt;Estrogen levels, which fluctuate according to the menstrual cycle and also dwindle as a woman enters gt;menopausegt;, have been linked to changes in how a woman feels pain, says Jennifer F. Kelly, PhD, a clinical psychologist at the Atlanta Center for Behavioral Medicine.gt;gt;The relationship appears to be complicated, however. Some studies have shown that women are more sensitive to pain when their estrogen levels are low (during menstruation, for instance), while others have shown the exact opposite. It's still unclear whether estrogen makes pain better or worse, Fillingim says.gt;gt;Psychological factors also likely play a role in gender-based pain differences. More so than men, who are apt to focus on the immediate physical sensation of pain, women tend to think about the consequences pain will have on their lives, Kelly says.gt;gt;"If a man hits his hand, his hand hurts," Kelly says. "But if a woman hits her hand, she focuses on the emotional aspects...and how it is going to impact day-to-day functions. Women tend to experience more pain as a result, possibly because the emotions associated with pain are usually negative."gt;gt;While this may sound like a cliche straight out of , it's backed up by studies that have used brain scans to identify the regions of the brain that respond to pain. When women and men receive the same pain stimulus, women show more activity in the emotional centers of their brains, while in men the cognitive and analytical areas of the brain tend `to light up.gt;gt;Other health conditions—most notably gt;depressiongt;—may magnify the emotional response to pain. Women are more likely to be diagnosed with depression, which is a risk factor for chronic pain conditions, says Kelly, who gave a presentation on gender and pain at a recent meeting of the American Psychological Association in San Diego.gt;gt;gt;How women copegt;gt;Strategies for gt;coping with chronic paingt; also differ between the sexes. These differences are potentially important, since how a person copes with pain can actually influence how much pain they feel.gt;gt;For instance, women are more likely than men to turn to friends, family, and other sources of social support to talk through how their pain is affecting them, Fillingim says. That's generally a good thing, but some studies suggest that women are also more likely to exaggerate their chronic pain and the negative consequences it has on their lives.gt;gt;This excessively pessimistic or melodramatic thinking—"catastrophizing," some pain experts call it—can backfire and make pain worse. It gt;tends to elicit hostilitygt; from spouses, family, and friends (rather than support), and it's linked to higher levels of pain and depression.gt;gt;The roles that women play in their families—as well as in society more broadly—can also shape how they cope with chronic pain, says Carmen R. Green, MD, a professor of anesthesiology and ob-gyn at the University of Michigan, in Ann Arbor. In some cases, expectations for women's behavior and their responsibilities can actually lead them to downplay their pain and try to fight through it—the opposite of catastrophizing. "Women will always take care of their kids, so it appears that they are functioning better because they have no choice," Dr. Green says.gt;gt;In some ways, women cope with pain more constructively than men do, Dr. Green says. "Women enter the health care arena sooner than men, which may be a positive coping step, and they tend to have a more varied and larger social networks," she says. The latter means they may have more shoulders to lean on when their pain is acting up.gt;gt;gt;Finding the right pain treatmentgt;gt;Despite the many differences in pain between genders, treatments aren't always tailored to women and men. And women in particular are at risk for having their pain poorly assessed and undertreated, Kelly says. (It probably doesn't help that the majority of pain physicians are men.) gt;Pain medicationsgt; often have disparate effects—and side effects—in women and men, according to Kelly. "Physicians working with females have to be aware that women have more side effects from medications, and have to work with them differently and find something that can be a benefit with the least amount of side effects across the board," she says.gt;gt;Doctors prescribe pain medicine based on how the drugs are metabolized by a 150-pound man, Dr. Green adds. "We have to do more clinical trials on women to see if age—and whether they are pre, peri-, or post-menopausal—affects how they respond to medications to treat their pain," she says.gt;gt;In many cases, gt;non-medical treatmentsgt; such as gt;cognitive behavior therapygt; may be especially beneficial for women, Kelly says. This brief, focused therapy addresses coping skills and seeks to change the thought patterns associated with pain (such as catastrophizing) and the impact they have on a person's quality of life.gt;gt;"We need to teach women to be good advocates for themselves about their pain and how it impacts their life, so that they can see their doctor and say 'This is where it hurts', 'This is what makes it feel better,' 'This is what I can do' and 'This is what I can't do," Kelly says. ]]> The female body and mind appear to process pain differently than a man's. Getty Images

gt;gt; gt;Q:gt; gt;How many people with chronic pain use complementary remedies?gt; gt;gt; gt;A:gt; gt;Surveys show that 40% or more of chronic pain patients use some level of complementary therapies. The number is high because pain is becoming epidemic. More people are experiencing pain, so you are going to have people who don’t get immediate relief and start searching for other options. According to several large surveys done by the National Institutes of Health, the needs of the pain patient aren’t always being met. So it makes sense that pain patients will ask, "What else is out there?"gt;gt; The most common treatments are manual therapies, such as massage or chiropractic, as well as herbal medicine, dietary supplements, gt;acupuncturegt;, and gt;mind/bodygt; therapies (a catchall phrase for techniques like gt;biofeedbackgt;, guided imagery, and gt;meditationgt;).gt; gt;gt; gt;Q:gt; gt;Should anyone with chronic pain consider adding complementary approaches to their treatment?gt; gt;gt; gt;A:gt; gt;Yes, within reason. There are obviously many approaches that fall under that umbrella. Most of them are benign treatments—you aren’t going to necessarily mess anything up by doing them. My advice is always to use a health-care advocate like a doctor who can give you unbiased treatment advice. If you are getting to a point where other things aren’t working, most rational health-care providers will bring up other options. But we need a larger knowledge base—84% of doctors feel uncomfortable discussing complementary and alternative medicine (CAM). When probed, they say that they don’t know enough about it.gt; gt;gt; gt;Q:gt; gt;How do the mind and body interact when you're in pain?gt; gt;gt; gt;A:gt; gt;We know pain can create very significant emotional and physical stress in the body. The stress component can cause a large cascade of stress hormones that go on to damage other parts of the body and place a huge burden on the brain. The brain literally changes from pain; the brain actually will lose part of the gray matter so you have a less functional brain. You also have more depression, more insomnia, and more anxiety—the nervous system becomes its own enemy. Mind/body therapies are an elegant avenue to retrain the brain, and one is not necessarily better than another. They are all shifting the mind to a better place. It might not take your back pain away tomorrow, but it can give you excellent coping strategies and increase awareness of what modifies the pain.gt; gt;gt; gt; gt;Q:gt; gt;Which complementary treatments should I try?gt; gt;gt; gt;A:gt; gt;It's not a one-size-fits-all approach. It depends on what you are looking for and what you are open to. If you are stressed out and want something relaxing, you might try guided imagery or hypnosis for pain. If you are very data-driven or analytical, you can try biofeedback. Yoga is gt;great for back paingt;, but one has to be open to the concept and the level of investment that may be required to see results. CAM is much like medication; you have to try different things until you find something that works.gt; gt;gt; gt;Q:gt; gt;How can I tell the difference between valid, effective treatments and miracle cures that could be dangerous?gt; gt;gt; gt;A:gt; gt;Anytime that someone is in a bad state of health, they may become desperate for relief. In some cases, people will try to take advantage of that scenario. So you need to have a health-care advocate to help you filter out all of the information. The best person to do that is a health-care provider or someone you trust, in the context of that experience. You can find a lot of information about valid treatments at the gt;National Center for Complementary and Alternative Medicinegt;.gt; gt;gt; gt;Q:gt; gt;What is the most important new research on CAM therapies?gt; gt;gt; gt;A:gt; gt;There is a lot of interest in research using functional MRI to show how acupuncture changes the brain. This is proving what they knew 3,000 years ago, that a needle between the first and second finger can help decrease pain; now we know it may be because it makes the limbic system less sensitive. There is also research on the effects of biofeedback and chronic pain, particularly fibromyalgia, irritable bowel syndrome, and recurrent abdominal pain. Another type of biofeedback being studied is heart-rate variability, a noninvasive way to look at how stressed someone is; low heart rate variability—when the heart is slow to adjust its rate in response to changing situations—is linked to high pain, high anxiety, and increased rate of heart disease.gt; gt;gt; gt;Q:gt; gt;Do you think complementary approaches will soon be part of mainstream pain treatment?gt; gt;gt; gt;A:gt; gt;In most of the world, people have some sort of CAM integrated into their treatment. Unfortunately, the United States is behind. We need more education and more basic efficacy research to show, for example, that a chronic pain patient feels better after 12 weeks of acupuncture. We are getting there, but it’s slow.gt; gt;gt; gt;Q:gt; gt;What can I do if my doctor is resistant to incorporating complementary approaches?gt; gt;gt; gt;A:gt; gt;Each patient owes it to herself to create the optimal health-care environment, which includes the doctor, the clinic, and the staff. Sometimes you have to find a different provider. You have to find someone you can work with, in terms of personality and the dialogue, and teasing that out is important.gt; gt;gt; gt;Q:gt; gt;How can I find a good CAM practitioner?gt; gt;gt; gt;A:gt; gt;Start by asking your doctor if he can recommend someone who works with CAM. If that doesn’t work, then go to a national or state licensing organization for whatever you are interested in, gt;acupuncturegt; or massage, for example. Pick a few names, call the providers, and make sure that everyone is on the same page. But again, make sure that you have a pain advocate who can advise you. They might tell you that a particular treatment isn’t good for you if you just started a new medication. There are ways now that providers can communicate, such as with electronic medical records, to make it a little bit easier. Remember, you shouldn’t be your own quarterback. You shouldn’t be riding the bike while you are trying to fix it.gt; gt;gt; ]]> (ROBERT BONAKDAR)

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gt;gt; gt;Q:gt; gt;Can a family doctor successfully treat chronic pain?gt; gt;gt; gt;A:gt; gt;The view of most primary care doctors is that they treat all pain as acute pain, no matter how long it goes on. gt;Acute paingt; should be thought of as ending in 30 days, then it’s subacute for 30 to 60 days, but after that it’s gt;chronic paingt;. The biology of chronic pain is not the biology of acute pain. If you fall and break your wrist, the bones will heal within four to six weeks, but pain may continue. You can’t treat that like you would the acute fracture.gt; gt;gt; gt;Q:gt; gt;What’s wrong with treating chronic pain acutely?gt; gt;gt; gt;A:gt; gt;The longer you go on with untreated pain, the more perpetuated the pain becomes and the more difficult it will be to treat. So if you’re treated in 60 to 180 days, your probability of being pain free goes to nearly zero. But if we can get you in the first 30 to 60 days, you might stay pain-free—from that particular problem—for the rest of your life.gt; gt;gt; gt;Q:gt; gt;What do you advise a patient to do?gt; gt;gt; gt;A:gt; gt;Take a little individual responsibility and say to the doctor, "I’d like to be referred to a gt;pain specialistgt;, or see an orthopedist." In the case of a fractured wrist, the family doctor will do an excellent job setting it. But once the cast comes off and the bone is healed, if it’s still hurting, you’ve got a problem. You may need to go to a hand rehabilitation program, you might need an injection into your neck that sort of resets the switch for your arm, you may need a comprehensive pain management plan ultimately. The sooner you can get to that level of care, the better the result will be.gt; gt;gt; gt;Q:gt; gt;You advocate comprehensive pain management—a combination of approaches such as drugs, counseling, physical therapy, alternative treatments—all coordinated by a team. How many patients actually get that in the United States?gt; gt;gt; gt;A:gt; gt;In the past decade, the number of large, multidisciplinary pain clinics has dropped dramatically, from more than 1,000 to fewer than 300 today. Even the federal government only operates one comprehensive pain clinic now, in Florida, through the Department of Veterans Affairs.gt; gt;gt; gt; gt;Q:gt; gt;Can you still find pain specialists?gt; gt;gt; gt;A:gt; gt;There aren’t enough—especially if you’re living in Middle America, you’re really hurting. There are very few pain clinics that you can go to. It’s going to take some legwork and maybe four hours of driving [from a small city] to get to some place that might give you the help you need. In a major city, though, you can drive down the road and find a big clinic.gt; gt;gt; gt;Q:gt; gt;Why the decline in pain clinics?gt; gt;gt; gt;A:gt; gt;The implosion has been partially because of managed care. We still pay for more nerve blocks and procedures than we do for multidisciplinary care, and yet the only thing that statistically has been shown to make a difference is multidisciplinary care.gt; gt;gt; gt;Q:gt; gt;Is insurance also a barrier?gt; gt;gt; gt;A:gt; gt;A lot of employers will shop every two or three years for the lowest priced health care they can buy. This year you’re with HMO ABC. Three years from now you’re with HMO XYZ. The records don’t move seamlessly around with you. The docs at each new place have some suspicion about what was done previously. And everybody knows you’re going to move again. So nobody wants to do the job right on their watch.gt; gt;gt; gt;Q:gt; gt;With all of these obstacles, aren’t you asking a lot of the patient to say that they must demand complex care for pain?gt; gt;gt; gt;A:gt; gt;I’m not asking for patients to do anything complex other than to take ownership of their problem and say they’re not happy. It’s arm that hurts. At the end of six weeks, if it’s still hurting, you need to be proactively saying, "I need to move on to the next phase." When the doctor says to just give it time, give it six months, you have to say, "No, no, no."gt; gt;gt; gt;Q:gt; gt;So even when you’re in pain, you have to take charge?gt; gt;gt; gt;A:gt; gt;I hope patients will just get the point. You don’t have to hurt. People suffer a lot more than they need to. And if they took a bit of action and became a so-called bad patient, became a little disruptive, said, "You know, this isn’t arm that hurts, it’s , and I want referral now, not in six months," things would be better.gt; gt;gt; ]]> "The longer you go on with untreated pain, the more perpetuated the pain becomes and the more difficult it will be to treat." (B. ELIOT COLE, MD)

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gt;OxyContin scandalgt;, drug companies are in a race to make it more difficult to tamper with prescription narcotics. In August, the Food and Drug Administration (FDA) decided to give priority review to a version of oxycodone (the active compound in OxyContin) called gt;Remoxygt;, which resists crushing, injecting, and dissolving in alcohol—all techniques used by street addicts to get a rapid high from what is supposed to be a slow-release drug. That followed an FDA rejection in May of a new version of OxyContin that was supposed to do the same thing. gt;gt;Getting tamper-resistant drugs to market will be a cash cow for the pharmaceutical industry, but it's not just companies who will benefit. If the drugs can cut the dangers and stigma of possessing legitimate-use narcotics in high-risk cities, the real beneficiaries will be patients in pain, says one expert in Baltimore, a city battling an entrenched drug problem. gt;gt;In her work there, Kathryn Walker, PharmD, an assistant professor at the University of Maryland School of Pharmacy and a clinical specialist in palliative medicine, often sees doctors and terminal cancer patients who are afraid of narcotics in the home, in part because they fear the drugs will be stolen by addicted relatives. (A 2007 study found that 70% of illicitly used prescription drugs were obtained from friends or relatives.) Drug abuse also has gravely distorted the perception of these drugs to the people who need them most. gt;gt;“You’re talking about a patient with end-stage cancer who is afraid to use gt;opioidsgt; because she’s seen what addiction has done to her family," Walker says. "She’s seen her cousin, brother, mother hooked on these agents. Anything we can do to ameliorate that would be helpful.” gt;gt;gt;gt;New ideas to foil street dealersgt;gt;Remoxy and the rejected new version of OxyContin both make the basic pill harder to crush, dissolve, snort, and inject. But Walker says several more novel anti-tampering formulas are working their way through the FDA approval process, and she’s optimistic some will make it. In one, tiny spheres of an active drug are commingled in a capsule with identical-looking spheres of an antagonist—a substance that neutralizes the narcotic effect if the capsule is crushed. (Taken orally, as prescribed, the neutralization doesn't happen, but the high isn't immediate either). gt;gt;In another formula, the active drug is mixed with capsaicin, the substance that gives chili peppers heat: Injecting or snorting results in fierce burning "at both ends," Walker says. gt;gt;In the third option, called the "pro-drug" approach, a drug is only activated by the metabolic process that takes place inside the human gut, turning your body into a chemist's lab. gt;gt;None of these measures prevent the simplest narcotic abuse—taking too much of a drug in its original form—but they make tampering tricky, and the street puts a premium on fast, intense highs. If the drug is too hard to jimmy, dealers will move on. ]]> Pharmaceutical companies are coming up with novel ways to outwit street dealers. (ISTOCKPHOTO/HEALTH)