NHS Choices

Shouting 'OW!' may help increase pain tolerance

NHS Choices - Behind the Headlines - Mon, 02/02/2015 - 16:32

The Daily Mail reports on what many people have long suspected to be the case: shouting "ow" (or something stronger) may help us cope better with pain.

The claim was prompted by a small study involving 55 people. They were asked to keep their hands in painfully cold water (4C) for as long as possible and were given various instructions, such as staying silent or saying "ow".

Those instructed to say "ow" when in pain lasted longest – around 30 seconds – along with those told to press a button to indicate pain. Both groups lasted longer than those told to remain silent.

Limitations of the study include its small sample of similar people (Singaporean university students in their early 20s) and the use of a specific experimental scenario.

These factors limit the generalisablity of its findings. It is unclear how representative the scenario is of different real-life pain situations.

Still, the study does raise the interesting question of why do people yell when they've been hurt. A possible explanation given in the past was this helped alert others of danger and attracted help.

The research team weren't able to explain the biology behind their result, but speculated the automatic messages travelling to the vocal part of the brain may interfere with the pain messages. But this was speculation and is not proved by the study itself.


Where did the story come from?

The study was carried out by researchers from the University of Singapore, and was funded by the university's department of psychology.

The study was published in the "Journal of Pain", a peer-reviewed science journal.

The Daily Mail's reporting was generally true to the facts, although they took all the findings at face value. For example, they stated that, "Crying out while feeling pain interferes with the body's pain signals".

This factual-sounding statement isn't backed up with evidence in the underlying study. There were other similar examples of this in the reporting.


What kind of research was this?

This was a human experimental study looking at how vocalising pain influences pain tolerance.

Anyone who has stubbed their toe in the morning or stepped on a piece of Lego barefoot will testify that vocalising is a natural and widespread reaction to pain.

The current study wanted to look at whether yelping and saying "ow" helps alleviate pain, and sought to discuss potential underlying mechanisms.


What did the research involve?

Participants were asked to submerge one hand in a room-temperature water bath for three minutes before dunking it into 4C water for as long as they could.

The length of time the participants held their hand underwater was timed. After they'd dried off, the participants were asked to rate the pain intensity felt during the experiment.

Participants repeated this test under five different conditions to see how vocalisation affected how long they kept their hand in the cold water and their ratings of pain intensity.

The five conditions were:

  1. Participants were allowed to say the word "ow" when they felt pain. They were not allowed to use other words.
  2. Participants heard their own "ow" voice played back to them from a previous recording. Otherwise, they were told to remain silent.
  3. They heard another person's "ow" voice played to them. Otherwise, they were told to remain silent.
  4. Participants were allowed to press a button on a response box to indicate pain. Otherwise, they were told to remain silent.
  5. Participants were asked to do nothing and say nothing during the cold test. This group acted as the main comparison group to which other conditions were compared.

The analysis was crude and did not account for any potential confounders, such as age, gender, or ethnicity. 


What were the basic results?

The main findings of this study were that:

  • saying "ow" and button pressing increased pain tolerance relative to doing nothing and saying nothing
  • hearing "ow", either their own voice or someone else's voice, was not linked to pain tolerance
  • pain tolerance while saying "ow" and button pressing correlated positively


How did the researchers interpret the results?

The research team concluded that, "Together, these results provide first evidence that vocalising helps individuals cope with pain. Moreover, they suggest that motor more than other processes contribute to this effect."



This small study showed saying "ow" out loud, or pressing a button as an outlet for pain, was associated with slightly more pain tolerance than remaining silent in a group of 55 university student volunteers.

The experiments involved participants holding their hands in very cold water for as long as they could.

In different scenarios, they were allowed to say "ow", hear someone else say it, hear a recording of themselves saying it, or press a button. These were all compared against immersing their hands while saying nothing and doing nothing.

The researchers wanted to see how any of this affected the length of time the participants could keep their hands in the water, or their ratings of pain after it was all done. It turned out pressing the button and saying "ow" were the only conditions linked to longer pain tolerance.

The study size was small and not representative of the general UK population. The average age was 21, and all the participants were students at the University of Singapore.

A larger and more diverse sample would have increased the applicability of the results. Gender and cultural norms might also influence how vocalisation affects pain tolerance, but this was not addressed.

The experiment was also quite artificial, so may not translate into the real world: participants were only allowed to say "ow". They were not free to say what they wanted, which might influence the results.

It is also unclear how representative this specific experimental scenario is of the many and varied real-life pain situations. In other situations, pain may be much more intense, longer lasting, and not so easy to instantly escape from – for example, childbirth or traumatic injury.

Pain situations in real life may also be mixed with emotional effects, which could influence our response in ways that this study has not examined. As it stands, we can't be sure these results are reliable or apply to most people. 

It would be interesting to see if similar results would be found in other pain scenarios, and to explore any potential beneficial implications. For example, should we be advising women in childbirth to shout from the rafters if there is potential for it to help the pain?

Based on this study alone, we can't give any meaningful advice. But it could be an avenue of research for the future.

Overall, we should take the results of this study with a pinch of salt. More evidence on the topic needs to accumulate before we can say vocalising pain helps people, or we can devise ways this could be useful to people in a healthcare setting.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

How saying 'ow' can ease your pain by interfering with signals to the brain. Daily Mail, February 1 2015

Links To Science

Swee G, Schirmer A. On the Importance of Being Vocal: Saying "Ow" Improves Pain Tolerance. The Journal of Pain. Published January 23 2015

Categories: NHS Choices

Ebola risk remains low after UK nurse recovers

NHS Choices - Behind the Headlines - Mon, 02/02/2015 - 15:40

The Scottish nurse found to have Ebola after arriving in Glasgow from Sierra Leone has recovered after specialist care at the Royal Free Hospital in London and has been discharged.

She remains the only case confirmed in the UK, and the risk to the general public is very low. Ebola can be transmitted only by direct contact with the blood or bodily fluids of an infected person.

The nurse, Pauline Cafferkey, had been working as a volunteer for Save the Children in Sierra Leone. She left Sierra Leone on December 28 and took flights from Freetown to Casablanca and from Casablanca to London. She then transferred at Heathrow to a flight for Glasgow.

The risk of infection to other passengers on the flights was considered extremely low. As a precaution, however, passengers and crew on the flights from Casablanca to Heathrow and Heathrow to Glasgow were contacted and provided with health information.

Passengers who were sitting near Ms Cafferkey on the flights were followed up and monitored. It has now been confirmed that no passengers were affected by Ebola.

The UK has well-established and practised infection control procedures for dealing with cases of imported infectious disease, and these will be strictly followed to minimise the risk of transmission.

Professor Dame Sally Davies, Chief Medical Officer, said: "It is important to be reassured that although a case has been identified, the overall risk to the public continues to be low.

"We have robust, well-developed and well-tested NHS systems for managing unusual infectious diseases when they arise, supported by a wide range of experts. The UK system was prepared, and reacted as planned, when this case of Ebola was identified."

More than 22,000 cases of Ebola have been confirmed in West Africa, with over 8,800 deaths – a mortality rate of around 40%.

Outbreaks of Ebola are nothing new, but health professionals are concerned about the size of the outbreak.

What is Ebola?

Ebola is a virus that can be spread through blood and bodily fluids. The virus originated in the West African rainforest and is thought to have spread to humans by handling or butchering infected animals.

Once the virus enters the body it can replicate very quickly, causing a range of increasingly harmful symptoms, including internal bleeding. Left untreated, it can have a mortality rate as high as 90%.


What are the symptoms of Ebola virus?

An infected person will typically develop a fever, headache, joint and muscle pain, sore throat, and intense muscle weakness. These symptoms start suddenly 2 to 21 days after becoming infected.

Diarrhoea, vomiting, a rash, stomach pain, and impaired kidney and liver function follow. The infected person may then bleed internally, as well as from the ears, eyes and mouth.


How is the Ebola virus spread?

People can become infected with the Ebola virus if they come into contact with the blood, body secretions or organs of an infected person.

Some traditional African burial rituals may have played a part in its spread. The Ebola virus can survive for several days outside the body, including on the skin of an infected person.

In parts of Africa, it is common for mourners to touch the skin of the deceased. A person then only needs to touch their mouth to become infected.

Other ways people can catch the virus include:

  • touching the soiled clothing of an infected person and then touching their mouth
  • having sex with an infected person without using a condom – the virus can be present in semen for as long as seven weeks after an infected person has recovered
  • handling unsterilised needles or medical equipment that have been used on the infected person
  • handling infected animals or coming into contact with their bodily fluids

A person is infectious as long as their blood and secretions contain the virus.

Ebola virus is generally not spread through routine social contact, such as shaking hands with patients without symptoms.

The virus is not airborne, so it's not as infectious as diseases such as the flu – you'd need to get close to it to catch it.


Who's at risk from Ebola?

Anyone who has close contact with an infected person or handles samples from patients is at risk of becoming infected. Hospital workers, laboratory workers and family members are at greatest risk.


How is Ebola diagnosed?

It's difficult to know if a patient is infected with Ebola virus in the early stages. The early symptoms of Ebola, such as fever, headache and muscle pain, are similar to those of many other diseases.

But health workers are on standby to act quickly. If anyone in the UK develops the above symptoms and has potentially been in close contact with the virus, they will be admitted to hospital and will most likely be quarantined.

Samples of blood or body fluid can be sent to a laboratory to be tested for the presence of Ebola virus, and a diagnosis can be made rapidly. If the result is negative, doctors will test for other diseases, such as malaria, typhoid fever and cholera.


What are the treatments for Ebola?

There's currently no specific treatment or cure for the Ebola virus, although potential new vaccines and drug therapies are being developed and tested.

Patients need to be treated in isolation in intensive care. Dehydration is common, so fluids may be given intravenously (directly into a vein).

Blood oxygen levels and blood pressure will be maintained at the correct level, and the body organs supported while the patient recovers.


What is the risk of Ebola in the UK?

The risk to the UK is thought to be very low, and, while someone with the virus can bring it to the UK, the risk of it spreading is very low.

Ebola virus is not airborne, so there is no credible risk of a swine flu-like global pandemic.

You cannot catch Ebola by travelling on a plane with someone who is infected, unless you come into very close physical contact with them – for example, by kissing them.


What precautions are being taken?

Public Health England (PHE), the body responsible for public health in England, has told health professionals about the situation in West Africa and asked for vigilance about unexplained illness in people who have visited the affected area.

PHE has provided advice for humanitarian workers planning to work in affected areas. It is also working with people from Sierra Leone living in England.

Advice has already been issued to immigration removal centres on carrying out health assessments for people who may have been in Ebola outbreak areas within the preceding 21 days.

PHE is also liaising with the UK Border Agency and port health authorities to update guidance for staff working in airports and ports.

Dr Brian McCloskey, PHE's director of global health, said: "The risk to UK travellers and people working in these countries of contracting Ebola is very low.

"People who have returned from affected areas, who have a sudden onset of symptoms such as fever, headache, sore throat and general malaise [sense of feeling unwell] within three weeks of their return should immediately seek medical assistance." 

Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Scottish Ebola patient transferred to London hospital – live updates. The Guardian, December 30 2014

Ebola healthcare worker transferred to London unit. BBC News, December 30 2014

Ebola patient transferred to London's Royal Free Hospital. The Daily Telegraph, December 30 2014

Nurse With Ebola To Arrive At London Hospital. Sky News, December 30 2014

Two more patients being tested for Ebola at UK hospitals. Daily Express, December 30 2014

Race to find hundreds of BA passengers who came into contact with UK nurse who brought Ebola back to Britain – but why did TWO screenings fail to spot her condition? Mail Online, December 30 2014

Categories: NHS Choices

Is asthma being overdiagnosed?

NHS Choices - Behind the Headlines - Mon, 02/02/2015 - 15:15

A potentially alarming figure that emerged in the UK news last week was that “1 million” UK adults may have been wrongly diagnosed with asthma – a claim reported in various forms by BBC News, The Guardian, The Daily Telegraph, the Daily Mirror and the Mail Online. 

The headlines followed the publication of new draft guideline (PDF, 670kb) from the National Institute for Health and Care Excellence (NICE) on the diagnosis and management of asthma. Most of the media articles were true to the facts and explained that the guideline was aiming to improve asthma care by improving the accuracy of diagnosis.

So, where did the figure of 1 million come from? All the UK press rallied round a statement in the draft guideline that said: “studies of adults diagnosed with asthma suggest that up to 30% do not have clear evidence of asthma”. What followed was clearly a “back of the envelope” calculation extrapolating this to the number of people receiving treatment for asthma in the UK, which is around 4.1 million. This gave the magic figure of 1.23 million potentially misdiagnosed people.

Unfortunately, the 30% figure in the draft guideline is not referenced, so we can’t find out how accurate it is. We also don’t know whether it applies to specific asthma subgroups, such as those of a specific age, or the severity of a person's symptoms. This makes it difficult to assess whether this calculation is accurate, or even reasonable.

The charity Asthma UK responded in a blog post, saying: “While we welcome the NICE guideline in the hope that it will help people with asthma to receive more personalised care, we are concerned that today’s headlines may make people think twice about taking their asthma medicines”.

“Although it is true that some people may receive treatment for asthma when they currently don’t have symptoms, this does not necessarily mean that they don’t have asthma. So it is vital that everyone diagnosed with asthma keeps taking their medication as prescribed and attends their annual asthma review”.

You should never stop taking any prescribed medication without first consulting with your GP or the doctor in charge of your care. This includes asthma medication.


What is the basis for these current reports?

NICE recently released a draft guideline to improve asthma diagnosis and monitoring.

The draft guideline – NICE's first on asthma – is now open for consultation until March 11 2015, so people and institutions can comment on its initial recommendations. The feedback and comments will be collated and incorporated into revised recommendations. Once agreed, these will form official NICE guidelines, which are expected to guide standard healthcare practice across the UK.

The draft guideline covers the diagnosis and monitoring of asthma in adults, children and young people. It draws on the best evidence available to determine the most clinical and cost-effective way to diagnose people with asthma and determine the most effective monitoring strategy to ensure optimum asthma control.


What does it say?

The draft guideline outlines that there is currently no gold standard test available to diagnose asthma. At the moment, it is mainly based on a thorough history of symptoms taken by an experienced clinician.

However, the guideline stresses that to achieve a more accurate diagnosis, clinical tests should be used alongside symptom assessment. The process the healthcare professional should follow in the initial assessment, and the tests to use, are presented in simple flow charts.

This involves using a combination of tests, depending on the age of the person being assessed. Most commonly this will involve a test called spirometry, to test lung function. This will sometimes be repeated after a person has been given inhaled treatment to dilate the airways – known as a bronchodilator reversibility test. Other tests that may be used include measuring fractional exhaled nitric oxide, as a sign of airway inflammation, and looking at whether the airways are over-responsive to inhaled substances, such as histamine or methacholine. 

The guidance also says that around one in 10 adults with asthma develop the condition because they are exposed to certain substances, such as chemicals or dust, in their workplace. Therefore, the draft guideline now recommends that healthcare professionals ask employed people how their symptoms are affected by work, to check if they may have occupational asthma.


How does the guideline affect you?

If you have asthma, do not change your medication without first consulting a doctor. This could be dangerous, as untreated asthma can be fatal.

If you have concerns that you have been misdiagnosed or are taking medicines unnecessarily, the first thing to do is speak with your health professional.

At present, these guidelines are in a draft form, so may be revised based on feedback and comment over the next few months. In the meantime, there aren’t likely to be changes in the way asthma is diagnosed routinely across the NHS. However, if the changes proposed in this draft make it into the final version, this may lead to a change in practice – most likely, more standardisation around the diagnosis and monitoring of asthma.

The main implications of such a change would be that the accuracy of diagnosing new asthma cases should improve or standardise for people in the UK. The implications for people already diagnosed with asthma are less clear. It could potentially mean that cases where there was uncertainty around the diagnosis would be re-reviewed with further diagnostic tests. This could potentially lead them to be declared asthma-free, or to a change in their medications, as appropriate.

This is a good reminder to take full advantage of your asthma review, which is an appointment with your doctor or asthma nurse to talk about your asthma and discuss how you can better control your symptoms. This is something that everyone with asthma should do at least once a year or more if you have severe asthma symptoms.

NICE says it wants to hear your views. Information on how to comment on the draft guideline can be found here.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Asthma diagnosis 'may be wrong' in one million UK adults. BBC News, January 28 2015

More than 1m people in UK may have been wrongly diagnosed with asthma. The Guardian, January 28 2015

More than 1m people with asthma may NOT have the condition and could be taking medication unnecessarily. Mail Online, January 28 2015

One million asthma sufferers may not have the condition, warns health watchdog. The Daily Telegraph, January 28 2015

Asthma: More than 1 MILLION people may have been wrongly diagnosed with the incurable condition. Daily Mirror, January 28 2015

More than 1m asthma sufferers may have been misdiagnosed. Daily Express, January 28 2015

Categories: NHS Choices