Time for Pain – Part 2

“There has been a shift in thinking away from pain as only a sensory experience. Rather than targeting the suppression of pain as a symptom, the best treatment now has to be targeted at preventing pain as a disease”

Dr Clifford Woolf, Neurologist of Children’s Hospital, Boston

New ideas on pain

  • Chronic pain is a normally adaptive process gone awry
  • There is a need for an all-encompassing approach to treat a disease of both brain and body
  • The anterior cingulate cortex is where the interpretation of pain takes place
  • The peri-aqueductal grey (PAG) is an area of the brain where the regulation or inhibitory actions to counter pain are derived
  • Endorphins stop the pain by attaching to nerve receptors reserved for opiates
  • Endorphins are linked to mood and can contribute to feelings of euphoria and satisfaction
  • “The brain may be able to be trained to secrete more endorphins” Dr Sean Mackay of Standford

National Centre for Complementary and Alternative Medicine (NCCAM) at the NIH

  • In its early years the focus was on debunking false claims
  • Now it spends more on figuring out what works for pain
  • A 2007 survey of 20,000 Americans showed that 40% of them has used some form of CAM in the previous 12 months
    • Pain relief was the most common reason for a visit
    • Eight percent went for massage therapy
    • Eleven percent had used meditation or deep breathing exercises
    • 3.1 million Americans (1.4% of the population) had had accupuncture

Categorization of chronic pain syndromes

  • Fibromyalgia Syndrome (FMS) is a condition whereby the patient must have widespread pain of at least 3-6 months duration, in 3 out o 4 quadrants of the body and is tender to the touch in 11 of 18 predetermined sites of the body.
    • In FMS there has been discovered more active nerve responses
    • FMS frequently have lower levels of endorphins
  • Complex Regional Pain Syndrome (CRPS) has replaced the term Reflex Sympathetic Dystrophy (RSD)
    • CRPS has a neuropathic type and a non-neuropathic component (enigmatic)
    • Both are associated with sympathetic disturbances, and therefore suggest an involvement of the sympathetic nervous system
  • Myofascial Pain Syndrome (MPS) is a painful condition caused by active trigger points (Time magazine completely neglected to acknowledge the contribution of trigger points to chronic pain conditions)
    • Active trigger points are palpable hardened or stiffened regions or zones found within taut (stretched) bands of muscle fibers that give rise to characteristic phenomena like local and referred pain. Pain evoked by pressure can include patient recognition of their familiar pain; is reproduced in a known pattern; can include a local twitch response, painful limitation of stretch range of motion; and some weakness of the muscle.
    • MPS is thought to account for 20% of all chronic pain

Some newly proposed treatment strategies

  • There are an estimated 8,000 doctors specializing in pain in the US. That’s one for every 9,500 chronic pain sufferers.
  • A quarter of all chronic pain sufferers switch doctors more than three times
  • A multi-faceted approach combines medication, procedure, manual therapy and psychological support
    • This is costly, complicated and rarely practiced
    • Touch
      • Self-touch reduces pain – that’s why we feel better when we rub the elbow after banging it into the fridge door
      • 2010 JACM published a single Swedish deep tissue massage lowered the hormone arginine vasopressin (AVP) and cortisol. AVP restricts blood vessels and raises blood pressure
      • Athletes have been known to train themselves to switch off pain – a punch to the boxer’s nose may hurt the first time but may be put up with over time
      • Training the brain
        • fMRI was used to give live access to the brain’s activity
        • Normal people could be trained to improve their response to a painful stimulation by 23%
        • Chronic pain people could be trained to improve by 64%
        • Other procedures
          • A spinal cord stimulator can work for neuropathic pain in the low back.

Once again the opportunity to include the myofascial trigger point contribution to chronic pain has been missed. The research in support of MPS in the last 5-10 years is undeniable. We can sample trigger points (‘biochemical milieu’, Jay Shah) and visualize them (Vibration Sono-elastography (VSE), Siddhartha Sikdar), both of the NIH in Bethesda, MD. Trigger points are now evidence-based. We always knew that they were evidence-informed, every time we palpated and deactivated.

I wait the day.