What's New in Veterinary Dermatology Anthea Schick, DVM, DACVD Every spring, the American College of Veterinary Dermatology (ACVD) and the American Academy of Veterinary Dermatology (AAVD) host a North American Veterinary Dermatology Forum (NAVDF). This April the NAVDF was held in Nashville, TN. The NAVDF is open to everyone with an interest in
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A Conceptual A Conceptual Model of Pain: Part three of this series discusses the choice of treatment approaches depending on the diagnosed source(s) of pain.
by James Woessner, MD, PhD In part one of this series,1the author de- becomes active (i.e. nociceptive pain may involvement from a herniated disc or scribed a conceptual model of pain based progress to neuropathic pain and then to other physical or chemical pathology at on electrical principles: sensors (free nerve central pain), the physician can address the nerve root exit from the spinal canal.3 endings), wires (axons/nerves) and the percep- one mechanism at a time by choosing While these distributions are usually un- tron (spinal cord and brain). Pain was de- treatment methods that are logically most ambiguous, specific mapping of the sen- scribed as either nociceptive (normal function- effective and logistically most convenient.
sory distributions of thoracic dermatomes ing of pain fibers), neuropathic (misfiring of Patient perception of treatment "reason- and the anatomic locations of the inner- axons/nerves), or central dysfunctions (central ableness" also plays a role in the initial vating nerves clearly show overlapping nervous system), the latter includes the pain treatment adopted.
and highly individualized patterns.
pathways in the spinal cord and the brain. Part Sclerotomal pain is deep bone pain re- two of this series discussed methods to measure Pain Patterns Related to
ferred from specific vertebral segments and quantify functioning of the pain nerve that may be interpreted as non-physio- pathways with a view to understanding the un- Having pathology is not the same as hav- logical. Bone pain may be either local or derlying pathology causing the pain.2 ing pain from that pathology. Without vis- referred from ipsilateral spinal segments.3 ible tissue changes, there may not be a pe- Pain referred from tendinous and/or ripheral pain generator, leaving neuro- ligamentous interfaces with bone surfaces The concept that pain results from me- pathic and/or central pain as the proba- has no specific name that may also be in- chanically- and chemically-caused physical ble cause. There could also be a micro- terpreted as non-physiological. Hackett4 changes that become more and more dif- scopic pathology and/or local metabolic mapped pain referred from ligamentous ficult to reverse is well-accepted through- reason. Ultimately, there must always be and tendon attachments to bones.
out Medicine. With the passage of time, the a mechanism whereby some pathology or Drs. Travel and Simons5,6 have provid- reasons for the pain also become multi-fac- dysfunction causes the perception of pain.
ed physicians and patients with detailed torial and overlapping, as well as more dif- There are, however, a multitude of pain- maps of referred pain patterns from my- ficult to cure. Thus, early treatment is bet- pathology referral patterns. Most physi- ofasical trigger points. While individual ter to avoid permanent physiologic and cians only recognize dermatomal pat- variations certainly occur, in general, structural changes and facilitate a cure.
terns; there are also sclerotomal, myofas- these patterns of referred pain can be rec- While the pain mechanism(s) may be- cial, viscerotomal, thermatomal, my- ognized in physician practice, and may come more complicated over time,1,2 as otomal, as well as other referral patterns.
sometimes be incorrectly referred to as more than one of the basic mechanisms Dermatomal pain suggests nerve root "non-physiologic" pain patterns.
Practical PAIN MANAGEMENT, Jan/Feb 2003
Likewise, the pain referral patterns of pathology in the in- table, complex, and difficult to cure over time. Anti-nociception ternal organs are well-known across multiple field of medicine.
can be a dysfunctional result in any type of pain.
Of course, there is an embryologic basis for these fairly consis- Environmental influences are certainly recognized to influence tent patterns of pain.5,6 pain. Cold, wet days make neuropathic pain (including CRPS, There are also thermal patterns of pain, which are probably re- myofascial, and fibromyalgia), worse. Just as old arthritics often lated to the distribution of sympathetic nerves (see Figure 1).7 comment that they "can feel" weather changes in their "bones," Butler8 has mapped referred pain from the spinal dura, which patients with neuropathic conditions often complain of more is also probably related to stimulation/irritation of the sympa- achy pain during bad weather. If consistent across these types of thetic C-fibers on the dura. Pain referred from the spinal dura pain patients, this phenomenon would support the concept that is reminiscent of thermatomes in being diffuse, but these refer- myofascial pain and fibromyalgia have, at least, a neuropathic ral patterns are unique.
Bonica and Loeser describe "myotomal" pain as involving Pre-morbid and secondary psychological/psychiatric condi- problems with the fascial tissue planes that surround muscle tions do often complicate diagnosing a pain condition. While groups.3 While "myotomal" may not be the correct description, depression may only sometimes be considered a cause of pain, when muscles were injected with hypertonic saline, which is an the converse is certainly true. Dissatisfaction, psychosocial emo- experimental substance known to produce pain, the above- tional stress and desire for secondary gain can occur concomi- mapped patterns of referred pain emerged.
tantly with objective physical pathology. In other words, the pa- Sometimes the myofascial pain referral patterns follow der- tient may present with a chronic condition that, in some ways, matomes, to some degree.9 Dermatomes are somatic sensory is exacerbated by a new injury.10 nerve distributions whereas trigger point pain referral patterns Basic individual personalities and cultural background have are more related to sympathetic C-fiber distributions.
a significant affect on the perceived degree of pain and dys- There is much to be investigated and considered before an function, i.e. the patient's reaction to the pain. Chronic pain integrated theory really useful to pain management can be ad- conditions are also often exacerbated by the withdrawal of fam- ily and friends support.10 Financial pressure to pay doctor's bills These different pain referral patterns may even occur simul- and maintain life generates stress, raises cortisol levels and con- taneously. If the physician does not pick out the correct primary sequently lowers pain thresholds.
pathology, treatment is — at best — a hit-or-miss "shotgun" ap- Pain and discomfort can essentially cause fatigue and sleep proach. This approach is demonstrated on a daily basis as many dysfunction, which further slows healing and increases suffer- physicians routinely — but consistent with the standard of care ing. Metabolic diseases, such as diabetes, may either be a pri- and training they've received — prescribe muscle relaxants, mary cause of pain, contribute in varying degrees to the pain, pain-killers (opioid/acetaminophen), NSAIDs (non-steroidal may exacerbate a psychological component or, in other cases, anti-inflammatory drugs) and sleeping pills to patients in acute may have nothing to do with the pain for which the patient and chronic pain.
It is important to note that "curing" the pain, as opposed to "masking" it, requires a specially trained physician to precisely and effectively decide the primary cause of a patient's pain prob- As presented in the second article of this series, the pain fibers lem and to pick the best and most effective treatment early in can transmit — or be perceived as transmitting — less or more their care. This exercise is the essential first step in deciding ona theoretically-based and pragmatically-possible treatment plan.
Interestingly enough, these different pain etiologies and pat- terns are most directly helpful in dealing with nociceptive pain.
In other words, these pain sources and referral patterns basical-ly represent normal neurophysiologic functioning and, by andlarge, provide the patient and the physician with useful infor-mation in determining a good working diagnosis for nociceptivepain. However, actual clinical presentations are usually morecomplex.
While somewhat arbitrary, acute and chronic pain are concepts
that must be considered and are useful in the sense that changes
of real consequence occur over time. There are typically many,
more complex, and permanent changes that do occur. Certain-
ly, most physicians have seen the very visible changes that can
occur in the natural progression of CRPS or RSD.
Neuropathic changes can also occur with CRPS and other pain FIGURE 1: Hooshmand7 has coined the word "thermatomes" to describe
conditions as illustrated in the 2nd of this series.2 If efferent referred pain patterns related to the circulatory distribution of sympa- pathways are either damaged or are responding in a reflex man- thetic nerves. These relatively amorphous distributions are consistent ner to aberrant afferent signals, then easily visible anatomic and with the observation that these C-fiber nerve pathways end up seeing structural changes can occur. These changes become more no- pain "through fogged glass." Practical PAIN MANAGEMENT, Jan/Feb 2003 signals than normal (damaged/dead and thetic C-fibers, making the procedure less CRPS likely involves all three, i.e. struc- irritated fibers, respectively). In addition, tural tissue changes that stimulate noci- there can be mixture of functional levels How can one really predict in each in- ceptors, malfunction of small pain neu- in a population of axons; the summation dividual case? Scientific results can be rons, and central neuronal changes con- of hypo- and hyper-function can result in supportive, but individualized, artful de- sistent with central hypersensitivity.1,2 average function that mimics normal cisions are the modus operandi through- out Medicine, particularly in Pain Man- Treating Nociceptive Pain
Small pain nerve (A-delta and C-fiber) agement. Protocols are to be viewed as Disease, pathology and pathophysiologi- pathology should intuitively have several guides — not the last word.
cal processes cause mechanical or chem- etiologies. Sudden trauma to a body part ical pain, which is usually nociceptive.
would seem to also have the potential to Physicians are most skilled at identifying damage by crushing the small pain No matter how complex the pain problems nociceptive pain as the pain-causing nerves, resulting in acute and then chron- of any individual patient, patterns of pathology. Unless the nerves themselves ic compressive neuropathy. An acute com- pathology do emerge and treatment op- are damaged or central pathways physio- pressive neuropathy may cause physical tions can be chosen. A framework must be logically altered, curing or removing the and chemical changes that can become a developed for approaching a pain problem cause is the physician's primary concern. chronic non-compressive and/or traction starting with diagnoses. Among these di- When it comes to cure, traditional al- neuropathy. Chronic repetitive rubbing agnoses, the physician must decide which lopathic physicians are most successful in can end up causing nerve dysfunction is primary, causative and/or dominant. treating nociceptive pain problems — as from similar physical and chemical con- long as neuropathic and central problems do not develop too quickly. For instance, These physical insults often cause local No matter how complex if a benign cyst is pressing on a nerve root, chemical changes manifest by swelling, it can be surgically removed and we would redness and hotness, i.e. inflammation.
expect resolution of the pain — unless Inflammation causes certain chemicals to neuropathic and/or central pain prob- the pain problems of any be released in the damaged tissues. There lems have developed.
are numerous such identified chemicals; a Neuron blockade and pain-killers of all few examples are prostaglandins, periph- sorts may be used initially to create "win- eral serotonin, kinins, histamines, etc.11 individual patient, pat- dows of opportunity" for cure. Chronicuse of pain-killers is condoned and med- The Problem with Treatment Protocols
ically honorable once the physician and Treatment protocols, as well as scientific the patient have made an honest effort to terns of pathology do experimental results, are problematic be- cure and to recover, respectively.
emerge and treatment cause each assumes that there is a range The following presents some of the au- of normal that must apply to every indi- thor's experience as an outpatient physi- vidual pain patient, whereas aspects of cal medical physician in treating noci- each individual patient's problem are ab- solutely unique. Pain is usually different RICE: Rest, Ice, Compression and El-
every day, and it changes unpredictably options can be chosen. evation are the elements of the tradition- over the course of the day. al approach in caring for acute sprain/ It is well known that even when it comes strains. The physician and the patient are to the mu-receptors in the spinal cord, By and large, most acute pain is noci- basically treating swelling, redness, hot- there are at least 10 types and each indi- ceptive. On the other hand, trauma can ness and pain. These modalities result in vidual has different proportions of these also damage the small pain nerves caus- less pain and expedite recovery. The ex- types. Obviously, it is impossible to pre- ing immediate neuropathic problems. For perienced physician may also include dict for an individual pain patient which example, the perceptron/central patholo- opioid will be effective and at what dose; gy for phantom pain, resulting from am- Physical Therapy: All of the PT
different individuals will have widely dif- putation or central disconnection, is modalities, including passive manual ferent opioid requirements for their pain.
probably established at the instant of trau- therapy and therapeutic exercises, are the Further, opioid requirements will change ma, but realized or perceived days, weeks, best curative approach. All sorts of pain- over the course of the day, every day, re- or months later.
killers and injections may very well pro- quiring more or less to control pain. Chronic pain most likely, but not nec- vide windows of opportunity for these ef- Treatment history can also have infinite essarily, involves all three types of pain — forts to be effective. The unifying princi- possible courses and happenings. If mul- nociceptive, neuropathic, and central.
ple of Physical Medicine — i.e. tissue re- tiple previous chemical blocks have pre- Varying degrees and patterns of these dys- molding — is facilitated and achieved, ceded efforts with electromedical nerve functions occur to result in the different however, by physical therapy.
blocks,12 the resultant scar tissue from the pain conditions. In some cases of arthri- Therapeutic Exercise: The most ef-
chemicals around the stellate ganglion tis, neither neuropathy nor central dys- fective tissue remolding technique is ther- will likely interfere with penetration of the function occurs. Fibromyalgia could be apeutic exercise under professional Phys- electric current to the underlying sympa- completely central, but not psychogenic.
ical Therapist supervision or at home. In- Practical PAIN MANAGEMENT, Jan/Feb 2003 fluencing the micro-environment of the nerve pathways makes sense and many probably not stimulators at all but, more tissue planes of the body by moving tis- patients are happy with the results. Radio likely, continuous neuron blockade of the sues with respect to other tissues, possibly frequency ablation is the preferred way to pain nerve pathways in the dorsal in conjunction with other procedures and burn or cut the offending nerves. Recur- columns. If these signals were indeed stim- therapies, is the key to cure. These exer- rence, on the other hand, happens fre- ulating, they would be stimulating pain.
cises include stretching, strengthening quently. Three possibilities come to mind: The classic gate theory does not apply in and endurance training-type of move- 1) a new transmission pathway develops, the author's opinion. Patients with SCSs ments that vary in intensity, repetitions, 2) local neuropathology develops from seldom state that pain relief in 100%; they sets, duration and session frequency.
the cut nerves, and/or 3) delayed central more often describe the sharp pains as Manual Therapies: Medical myother-
hypersensitivity sets in.
being reduced but with the nagging, burn- apy, deep soft tissue massage, rolfing, IDET: Intradiscal electrothermal re-
ing and aching pains remaining.
neural flossing,8 the Gunn technique13 duction of herniated nucleus pulposus is Intrathecal Drug Pumps: Distribution
and numerous other strengthening exer- a procedure that would seem to reduce ports are surgically placed in the epidur- cise techniques can be artfully integrated the morbidity of full-blown surgical pro- al space, where combinations of various with other above-mentioned treatments cedures. However, the author's experi- painkillers and muscle relaxants are de- for resolution of a patient's pain.
ence has been that third party payors have livered. In the author's opinion, these Chiropractic Care: Chiropractic care
resisted accepting this procedure. In the pumps are probably overused. Instead, usually includes modalities and thera- situations that IDET is unsuccessful, the optimized use of slow release opioid peutic exercise identical to those used in problems may be due to microscopically preparations and muscle relaxants are physical therapy. Unique, but not propri- etary, aspects of chiropractic care include When nothing can be done to correct applied kinesiology, activator adjust- Disease, pathology and the underlying cause, the pain can, of ments, high-velocity and low-velocity course, be dysfunctional and require tra- joint manipulations of various descrip- ditional and well-accepted pharmaceuti- tions and the use of multiple modalities.
cal pain control.
Chiropractic can be very a useful facet ofa multidisciplinary pain management ap- The Pharmaceutical Approach
These pharmaceutical suggestions are the Injections: There are injections done
processes cause author's preferences based on the known primarily to reduce pain, to reduce in- mechanisms of actions (pharmacokinet- flammation or to stimulate natural ics) and location of action inside the body. processes. Local anesthetics, catabolic Oral Opioids: Opioids are probably
mechanical or chemical steroids and proliferative agents are used, the safest of all the pain-killers. However, pain, which is respectively. The efficacy of the injections for those patients suffering from neuro- described below depend on the correct- pathic pain alone, pain management ness of the diagnosis, the physician's un- health care professionals recognize that derstanding of the utility and effect of the opioids merely "take the edge off," while injected substances, and finally whether many patients recognize no help at all.
the injected substance reaches the target usually nociceptive. For this specific population, patients re- porting that opioids "take the edge off " Local anesthesia ideally blocks the pain may, in fact, be potentially addicted. On and provides a window of opportunity for rough surfaces remaining after disc ma- the other hand, opioids typically do le- sleep, reduced stress, and various thera- terial is destroyed and possibly from the gitimately benefit those patients who have peutic activities. resulting reduced disc height. This as- nociceptive pain (with or without neuro- Catabolic steroids, by definition, break sumes that the diagnosis was correct in pathic pain). The author's professional down tissue. If the physician does not want the first place since discography is often experience confirms that when the noci- tissue breakdown, steroids should not be not predictive of the causative pathology.
ceptive pain patient is freed from the dis- used. Reducing abject inflammation Surgery: Whole textbooks are written
tractions of the pain, there is commonly and/or softening pain-causing scar tissue about lumbar surgery. Short-term out- an improvement in mental function.
are reasonable goals for steroid injection. comes have been reasonable, but long- NSAIDs: Non-steroidal anti-inflam-
Proliferative agents are intended to in- term results have been disappointing. Mi- matory drugs (both COX-1 and COX-2) in- crease healthy collagenous tissue. Pro- crodiskectomy has about the same draw- hibit inflammation and provide analge- lotherapy is beginning to receive scientif- backs as IDET. Metaphorically speaking, sia.16 Inhibiting the inflammatory cascade ic support14 and wider recognition among laminectomies and various types of fusion may be beneficial to prevent tissue dam- surgeries are really major trauma. Like age for the first few days. During more ad- Radio Frequency Ablation: If periph-
many things in Medicine, sometimes a vanced healing phases, a normally func- eral pathology is chronic, purely noci- poisonous medication or a traumatic pro- tioning inflammatory process is necessary ceptive, without removable pathology cedure is used to benefit when other, more for the best possible tissue recovery. While and without neuropathic or central dis- conservative, approaches fail.
the NSAIDs are not recommended beyond ease, burning or cutting the offending Spinal Column Stimulators: SCSs are
the first days of an acute injury, they may Practical PAIN MANAGEMENT, Jan/Feb 2003 be useful in clearly chronic disease for Pertofrane®). TCAs have data to support tagonizing actions at the presynaptic ter- analgesia, but the side effects of GI prob- some effcicacy in fibromyalgia. The SSRIs minal, neither nociceptive nor neuro- lems, kidney dysfunction, and possibly include fluoxetine (Prozac®), paroxetine pathic pain signals should be perceived heart problems with the COX-2 NSAIDs, (Paxil®), citalopram (Celexa®), sertraline must be closely monitored — especially in (Zoloft®) and venlaxine (Effexor®). The Since the physician's best efforts are fre- elderly and immune-compromised pa- biochemical precursor to Serotonin is the quently unsuccessful, understanding of tients. Ibuprofen and Naproxen are over- amino acid, tryptophan, which is available pain transmission must be less than per- the-counter NSAIDs. in turkey meat. Supplementation may be fect. What is known is that the pain signals Other OTC Meds: Acetaminophen and
reasonable in those depressed, not sleep- are weakened by encephalin-induced aspirin are the main remaining OTC ing, and with resulting exacerbated pain. dynorphin activity in the spinal cord.
pharmaceuticals. Both are underappreci- Anticonvulsants and Antiarhythmics:
Dynorphin activation of kappa receptors ated yet are effective pain-killers and can Rowbothan & Petersen19 only mention on inhibitory interneurons causes the re- be excellent low level pain control agents one antiarhythmic, i.e. mexiletine. It lease of GABA, which hyperpolarizes dor- for mild pain, depending on the individ- along with carbamazepam (Tegretol®), sal horn cells and inhibits further trans- ual patient. Each can be used on a daily gabapentin (Neurontin®), lamotrigine mission of the pain signal. This latter basis for long periods. However, chronic (Lamictal®), phenytoin (Dilantin®), topi- mechanism is especially important in use of acetaminophen can cause liver ramate (Topamax®) and valproic acid (De- modulating visceral pain. Medications and/or kidney failure, while chronic use pakote®) can be considered membrane- that mimic the efforts of endorphins and of aspirin can cause acute GI bleeding. stabilizers in the sense that most of these encephalins are the mainstays of chronic Muscle Relaxants: Lioresal (Baclofen®),
pain therapy. Newer drugs that mimic or carisoprodol (Soma®), chlorzoxazone potentiate the effects of GABA or alpha2- (Paraflex®), cyclobenzaprine (Flexeril®), Remembering that neuro- receptor agonists have made it possible to diazepam (Valium®), methocarbamol target therapy for chronic pain syndromes (Robaxin®), orphenadrine (Norflex®) and more specifically than in the past."20 tizanidine (Zanaflex®) are all commonly Most utilized pharmaceutical mecha- pathic pain is related to used muscle relaxants.17 Lioresal works at nisms are basically antinociceptive in na- the GABA receptors discussed below and ture. It may be that all of the antagonists could, via antinociceptive mechanisms, must be supplied simultaneously. Further, reduce reflex muscle contraction. Cariso- nerve (wire) dysfunction Brookhoff20 suggests more complex in- prodol is preferred by many patients as it teractions involving sympathetic and often helps with sleep, yet poses problems parasympathetic nervous systems that, due to its addictive characteristics. Cy- being poorly understood at this time, are itself, curative treatment clobenzaprine is related to the tricyclic without pharmaceutical approaches. must, therefore, focus on "
antidepressants and probably works cen-trally and it can also be useful for sleep.
Treating Neuropathic Pain
The author seldom uses chlorzoxazone, Radiological imaging of the spine and methocarbamol and orphenadrine, each brain are rarely helpful in determining of which is in a pharmodynamic class of neuropathic, central, or even nociceptive its own. Tizanidine (discussed in a subse- reversing that pathology. pain. Nerve damage can occur via an in- quent section) works at receptors on pe- finite number of mechanisms, and result ripheral nerves, spinal cord neurons and in several outcomes, i.e. hyperesthesia central neurons.18 medications reduce ectopic extraneous and/or hyperalgesia, paresthesias and/or Lidoderm: While there are analgesic
nerve firing by blockade of sodium chan- allodynia, or hypoesthesia; the ultimate creams, Lidoderm, at present, is the only nels. Clonazepam is a benzodiazepine hypoesthesia is the complete inability to topical preparation that comes as a patch.
that is included by Rowbothan and Pe- experience any pain at all. Remembering When using all topicals, the physician tersen, but works mostly like diazepam.
that neuropathic pain is related to nerve must remember that the depth of the pain Carbamazepam is the only one of these (wire) dysfunction itself, curative treat- nerves can be a problem; in other words, indicated as safe and efficacious for pain ment must, therefore, focus on reversing these preparations work better when by the FDA. Tegretol and Neurontin may causative pathology is near the skin sur- also work synergistically and are also used Other than trying to mask the pain by face. The chemicals do not penetrate or for mood disorders. means mentioned above, nutritional ap- diffuse in effective quantities deeper, be- proaches should be primary and synergis- cause the circulatory system absorbs and Sites of Pharmaceutical
tic. Omega fatty acids (6 to 3) in the ratio gradually disperses the active ingredients of 4 to 1 have been shown to optimize as the chemical penetrates deeper.
Pain signals from free pain nerve endings nerve function. Since Omega fatty acids SSRIs and Other Antidepressants: Tri-
and from dysfunction peripheral nerves are the building blocks for nerve mem- cyclic antidepressants (TCAs) include are conveyed to the perceptron through branes, we would expect that supplement- amitriptyline (Elavil®), imipramine the synapse of the peripheral nerve on the ing a neuropathic pain patient's diet would (Tofranil®), nortriptyline (Pamelor®, Aven- dorsal horn of the spinal cord. Theoreti- be a reasonable approach to suggesting til®) and desipramine (Norpramine®, cally, if those signals are blocked by an- cure. We would expect 4 to 6 months to Practical PAIN MANAGEMENT, Jan/Feb 2003 elapse before the patient or the doctor may natural-healing and anti-immune. It is quately educated the pain patient. Even see any noticeable improvement.
well known that increased cortisol lowers so, a couple of examples may be instruc- In a previous article,12 the author re- pain threshold. Psychophysiological fac- tive at this juncture. ported that medium frequency, especial- tors with complex interactions are obvi- Complex Regional Pain Syndrome ly 20,000 Hz, alternating current across a ously involved in pain perception.
(CRPS), previously named Reflex Sympa- tissue culture resulted in utilization of The most logical treatment approach is thetic Dystrophy (RSD) usually starts with cyclic AMP.21 Understanding the role of to use methods that directly affect neu- neuropathology of the A-delta and C- cyclic AMP suggests that normalization of rons in the central nervous system. Tran- fibers caused by acute or repetitive trau- nerve function can occur by stimulating scranial and body stimulation, auricular ma. Damage to efferent nerves causes vis- anabolism. Masking neuropathic pain can and traditional acupuncture, reflexology, ible physical changes that are well-de- also occur via electric neuron blockade.
applied kinesiology, yoga, imagery, and a scribed in CRPS/RSD. Also many researchers In both cases, we would expect that the whole range of psychological techniques have noted intracranial changes,24 which unmyelinated C-fibers would benefit are valid possibilities. are most likely subcortical. CRPS/RSD is a more than the A-delta fibers.
Nutritionals, such as gingko, may also non-standard, variable disease, and as Supplemental to the above approach- play a role.22,23 We would expect nutri- stated, varies among individual patients.
es, is the use of so-called membrane sta- tionals to be the building-blocks of repair Even before the name of Reflex Sympa- bilizing medications; these medications and normalization of function. Since sub- thetic Dystrophy was changed to Complex appear to stabilize nerve membranes by tle nutritional deficiencies or medicinal Regional Pain Syndrome, it has been ap- antagonizing signal transmission at spe- needs take time to develop, we would also preciated that these neuropathies involve cific receptors on pain nerves to prevent expect that repair would likewise take more than one type of nociceptive fiber.
hyperactive flow related to transmission months to years (see the section on the Fibromyalgia is another common of pain signals. These medications are role of nutritionals).
chronic disease which, in the authors mostly anticonvulsants, but also include Sometimes psychiatric conditions, such opinion, has probable involvement of the tricyclic antidepressants and antiarrhyth- as depression, anxiety and Post-Traumatic three pathologies supported by the pain mics. Zonegran blocks sodium, T-type cal- Stress Disorder (PTSD) are the cause of pain model described in this series. However, cium and K-evoked glutamate receptors.
and discomfort. It has been scientifically because of the dynamics of post-traumat- Neurontin (gabapentin) and Gabatril are confirmed that depression, at least, can be ic fibromyalgia and the patchiness that reported by Brookhoff20 to have actions correlated to central neurochemical the author has observed, it is suggested unrelated to GABA receptors shown above.
changes. Such chemistry can be modulat- that fybromyalgia probably starts periph- With knowledge of the nerve fiber type ed via Selective Serotonin Re-Uptake In- erally. But fibromyalgia also surely has involved, specific, focused treatments hibitors (SSRIs) and other antidepressants. central components because of the asso- may be possible. Neuropathic pain, as it's Pharmaceuticals that pass the blood- ciated cognitive and emotional sequelae usually used, refers to a burning, aching, brain barrier may also have potential for and concommitant symptoms.25 non-localized pain which points to in- cure, but so far appear to only suppress While not curative, Zanaflex® has been volvement of the C-fibers. The usual the pain sensation. In the same sense of found by the author to be the best phar- treatments are pharmaceutical. Thus, membrane stabilization, anticonvulsants maceutical for directly treating combined when the area pain is regional in nature, and other pharmaceuticals mentioned nociceptive, neuropathic and central the physician must, in consultation with above, have also been documented to be causes of pain with the least side-effects.
the patient, decide, depending on the useful for treating pain with central com- Zanaflex® is a basic alpha2 adrenergic ag- character of the neuropathic pain pres- onist active in the polysynaptic pathways ent, whether bathing the whole body in a Because mechanisms are still in the in the spinal cord and in the locus pharmaceutical, the possibility of de- early stages of discovery, psychogenic ceruleus and is unique in its widespread pendence and the expense are worth the causes of pain may very well be eventual- sites of action.18 minimal general pain relief and/or pain ly understood to be either chemical or relief in a single region.
anatomic (neuronal) changes in central Tissue Remolding and Tissue
pain perceptor systems.
Treating Central Pain
Physical Medicine includes numerous Central pain, according to the author's Treating Combined Pain
techniques to remold tissue. These in- definition, is any pain resulting from dys- As indicated previously, almost all chron- clude modalities and body movement im- function of neurons of the central nerv- ic pain is a combination of the nocicep- plemented by both active and passive ous system, i.e. the brain and the spinal tive, neuropathic and central pain with- means to change the micro-environments cord. Thalamic pain and phantom pain out a clear single pain generator. Books — both intra-cellular and extra-cellular. fall in this category. Perceived body pain have been written considering all aspects Tissue remolding, in a microscopic in complete spinal cord injured patients of various pain syndromes, yet protocols sense, is the changing of the microenvi- must be central in origin and mainte- and set recipes are too restrictive for the ronment. This phenomenon is mostly col- infinite variations found in patients. Each lagen remolding. However, other aspects Because elevated cortisol is known to be patient is an unique individual, whose of this microenvironment are likely in- anti-inflammatory in the human body, we condition varies from minute to minute.
volved. Temperature, pH and other would thus also expect that any stress There is no substitute for a knowledge- chemical parameters almost certainly causing increased cortisol will also be anti- able, flexible physician who has ade- come into play. Nutritional building Practical PAIN MANAGEMENT, Jan/Feb 2003 MANAGING CHRONIC PAIN IN TEN EASY STEPS
Be Realistic. Be honest with yourself and learn all you can about your physical condition. You may well have to deal with the fact
that your will need to deal with pain every day. Dealing with anger, frustration and change is an important part of the process.
Get Involved. Take an active role in dealing with your condition. Find out about all options available to you and move from a
passive to an active role in your healthcare. You may wish to look at non-medical options for support and help. Alternatives
such as acupuncture, homeopathy and looking at diet may be useful.
Learn Relaxation and the Value of Distraction. This isn't about booze and smokes! Learning to breathe and relax properly
distracts your mind and gives mind and body a break from the suffering associated with pain.
Recognize Thoughts and Feelings. The mind affects the body and the body affects the mind. Identifying your thoughts and
feelings is vital if you want to change how you relate to your pain.
Safe Movement. Safe movement combined with deeper breathing can improve mobility and make you feel more positive.
Set Priorities. With limited energy and mobility, it is important to look at what matters in your life. Ask yourself: "What do I
want?" Never mind the "should's".
Set Realistic Goals. Break big tasks into smaller more manageable steps that you can achieve. Pace yourself; continually
review pain and energy levels relative to activity. you will feel more in control.
Know Your Basic Rights. You have the right to be treated with respect, to say "no" without guilt, to do less than humanly pos-
Communicate. Communicating clearly and effectively with family and friends and colleagues reduces anxiety, tension, stress,
and suffering. Learning how to get your needs med is an important part of pain management.
STEP 10 Rediscover Hope. By using these strategies you will find that you can: Regain control; Increase your sense of well-being; Step
out of the pain-tension-anxiety-stress-cycle; Begin to get your needs met; Lessen suffering. TABLE 1. Self-help steps in managing chronic pain developed by the Pain Association Scotland.
blocks, as well as fibroclastic and fibrob- and/or hypoactive, depending on the fibers in tissue planes and around other lastic cells, must be present. axon within the "cable" of the whole nerve.
structures such as nerves. Because these Circulation changes affect microenvi- These tissue plane micro-environments are unmyelinated, it makes sense that ronmental chemistry. If circulation is may be mobilized by stretching, neural electrical energy, as a treatment modality, modified, then it's fairly certain to change flossing,8 strengthening, manual therapies would more likely penetrate these nerves the biochemical environment of the pe- to include various massage techniques, and thereby provide immediate pain re- ripheral areas involved. More blood rolfing, other deep soft tissue techniques, lief while promoting recovery of any C- means more nutrients and more disper- craniosacral techniques, etc., and thera- fiber pathology and malfunction.
sal of metabolites, and vice versa. Like- peutic exercise. The unifying principle of Changes occur even at the nociceptor wise, microenvironmental chemistry af- physical medicine for the cure of soft tis- terminal level in any chronic pain condi- fects circulatory changes thereby illus- sue pathology is tissue remolding. tion. Brookhoff20 gives a detailed descrip- trating the complex interrelationships.
tion, including the production/release of Efferent sympathetic C-fibers control Chronic Pain in Perspective
natural painkillers in the chronic pain sit- peripheral microenvironmental circula- Chronic pain includes CRPS/RSD, fi- uation. Methods to naturally stimulate tion. This makes microenvironmental bromyalgia, central pain conditions and the release of native pain-killers such as conditions directly related to local and sys- any pain that is present for long periods endorphins and enkephalins would seem temic sympathetic nervous system func- of time, is not likely to resolve, and man- to be an ideal way to promote natural pain tion — via reflex actions or centrally. This ifests in anatomic/physiologic changes.
control. Brookhoff also shows how potent can be understood starting first with cen- Chronic pain of any kind almost certain- inflammatory and vasodilating agents are tral control of the peripheral circulation. ly includes combinations of the above released following prolonged sensitiza- Microenvironments can be intracellular, pathologies, simply because one can pre- tion of the cells in the dorsal horn.
where metabolism is controlled or regu- cipitate another. Successful treatment, of course, de- lated by second messengers, or extracel- In general, chronic stimulation of no- pends on the exact cause. However, even lular. The most important extracellular ciceptors results in permanent physiolog- with clear peripheral pathology causing micro-environments are the tissue planes ic and microanatomic changes. While nociceptive pain, most of the treatments between tissue systems. As stated above, acute pain response is in the nociceptor mentioned above probably have less these microenvironments contain the A- terminal and is facilitated by glutamate, probability of providing a complete cure delta and C-fibers that carry pain signals.
chronic pain is more involved and com- because of the neuropathic and central If these micro-environments are altered, plex. Most chronic conditions include logically we would expect that the fiber malfunctioning sympathetic C-fibers. It is In reality, the only proven approach for would become hyperactive (irritated) well known that there are numerous C- chronic pain to date is counseling the pa- Practical PAIN MANAGEMENT, Jan/Feb 2003 tient to deal with the pain and develop- vides a rationale for the neuropathy of the stellate ganglion — will likely interfere ing a pain management plan involving cobalamin deficiency. Odd-chain fatty with penetration of electric current to the long-acting opioids.26 After all else has acids would build up in membrane lipids sympathetic C-fibers by any subsequently failed, covering up the pain in the con- of nervous tissue, resulting in altered attempted electromedical nerve block.
text of a chronic pain program is an ac- myelin integrity and demyelination, lead- Note that electromedical nerve blocks of cepted and honorable approach to im- ing eventually to impaired nervous system the stellate ganglion are more difficult to proving the quality of life of the pain suf- confirm than chemical blocks, in part be- ferer. A comprehensive self-help program It is reasonable to postulate that the use cause the Horner's sign is subtler.
for managing chronic pain, developed by of nutritionals effects the entire pathway, In the face of allodynia and hyperes- the Pain Association Scotland,27 is pre- including the peripheral nervous system thesia, electromedical treatments and sented in Table 1.
and the central nervous system — all the other therapy may also directly help de- way through the spinal cord and into the crease disuse atrophy and cure some dis- The Role of Nutritionals
eases that otherwise cause muscle atrophy, Proteins, carbohydrates, fats, vitamins skin color changes, and functional de- and minerals are all building blocks for The Role of Electric Medicine
creases in strength and ROM. tissues and cells. Nutritional precursors That there are electrical aspects to human are necessary to allow the body to metab- physiology is well-accepted. Note that The Role of Complementary/
olize appropriate bi-products for cure and EKG, EEG, EMG, nerve conduction stud- Alternative Medicine (CAM)
normalization of function and structure.
ies, evoked potentials, pace makers, All kinds of acupuncture (traditional, au- Basic nutrition promotes good health.
ricular and electrical), reflexology, koryo However, there is another approach that (Korean hand acupressure), etc. likely re- can be used separately or concomitantly.
sult in reprogramming neurons to normal In the face of disease, medicinal doses are function. These techniques, when they necessary and useful. This approach is to work, would then logically work better for encourage the patient to supplement his central nervous system pain dysfunctions.
are necessary to allow or her diet with so-called building block Herbal approaches are by and large not proven in a Western scientific sense. The Glucosamine sulfate is a known build- role and value of nutritional is gradually ing block for collagen. Besides being a the body to metabolize finding scientific support, but the "proof " logical nutritional for arthritis, it could is slow in coming. play a role in neuropathic pain, because A recently published 656-page refer- collagen has been shown to form the ence volume deals specifically with the appropriate bi-products for sheaths around nerves — the micro-envi- subject of using Oriental Medicine tech- cure and normalization of "
ronment of nerves. niques to treat pain.29 The pain etiology Omega fatty acids have roles in the is based on the Chinese concepts of ex- health of many body systems. Here, we ogenous factors. are interested in its presence in nervemembranes. Certainly, for the body to The Role of Science
heal damaged nerves (i.e. neuropathy), function and structure. The basis of science is manipulating one omega fatty acids should be in abundant variable at a time and measuring the re- supply. When it comes to nerves, the sult as manifest by another single variable.
proper balance of omega fatty acids can TENS, SCS, etc. are used throughout Med- Applying science to the function of an in- reconstitute the walls of irritated and icine. The scientific basis for electric dividual variable, such as nutritionals, is damaged sympathetic C-fibers. Healthy nerve blocks has previously been reviewed antithecal to actual pain presentation.
nerve membranes may very well equal Real-world patient presentation is very more normal nerve function.
Intra-cellular changes21 are most likely complex and involves multiple variables DL phenylalanine has been shown to promoted by so-called medium frequen- working synergistically or antagonistical- facilitate the production of endorphins in cy alternating current applied along body ly to give multiple results of interest.
humans. Since it is an essential amino parts where cellular dysfunction occurs, Certainly science helps physicians ob- acid, it could very well be an ingredient and nutritionals. We cannot rule out the jectively analyze things happening in in the endorphin recipe.28 importance of changes in intracellular health care world around us. However, Vitamin B6 is well-known biochemical- chemistry that are caused by stress and many physicians, especially those with re- ly to be a co-enzyme in the energy cycle.
other psychological phenomena. search training and advanced scientific Energy is required for metabolism. Heal- For best results, the right diagnoses are degrees, recognize that a very small per- ing is a metabolic process. It has been necessary so that the specific pathology centage of clinical medicine is based on used for years by general practitioners can be treated and the electrodes correct- scientific, double-blinded, controlled, and nutritional experts for various kinds ly placed. Treatment history also can have peer-reviewed proof. Certainly, no such of soft tissue pain.
unanticipated results. For example, multi- evidence exists for the effectiveness of ap- The association between vitamin B12 ple previous chemical blocks — resulting pendectomies. Deductive reasoning and and abnormal fatty acid synthesis pro- in chemical-induced scar tissue around experience allows physicians to accept Practical PAIN MANAGEMENT, Jan/Feb 2003 and use this surgical technique as the pathology towards a cure rather than romusculoskeletal Pain taken from Chapters 7 & 13.
"standard of care." Myofascial Pain and Fibromyalgia: Trigger Point Man-agement. 2nd Edition. Rachlin, ES. and Rachlin, IS.
Logic and scientific information can be With the realization that pathology, (eds.) Mosby. 2001.
applied and the results can be valuable particular in chronic pain, can involve no- 10. Main CJ and Spanswick CC. Pain Management: without a rigorous scientific experiment ciceptive, neuropathic and perceptron An Interdisciplinary Approach. Churchill Livingstone.
New York. 2000. 438 pp.
being done. In fact, the real world of med- (central) pathology together and in com- 11. Trowbridge HO and Emling RC. Inflammation: A icine is not a place where "real" science plex individually varying patterns, inte- Review of the Process. 5th Edition. Quintessence can be done, because the real world is grated medical treatment is the only way Books. Carol Stream, Ill. 1997. 236 pp.
complex and the best medicine is prac- to have reasonable hope of optimizing 12. Woessner J. Blocking out the Pain. Practical Pain ticed on individuals — not populations.
pain care. These pain conditions can be Management. Mar/Apr 2002. pp. 19-24.
The population approach, based on the so complex that we fully expect a new field 13. Gunn CC. Treating Myofascial Pain: IntramuscularStimulation (Ims for Myofascial Pain Syndromes of mathematics of statistics, has spawned of medicine to be developed, such as Pain Neuropathic Origin). Churchill Livingstone. NY. 1996.
"guidelines," "protocols" and "hard-and- 14. Reeves KD. Prolotherapy: Basic Science Clinical fast" rules. "Protocols" are helpful, but Each of the opinions stated above can Studies and Technique. Lennard Pain Procedures inClinical Practice. Hanley and Belfus Inc. Phila. 2000.
should not be controlling.
be supported from the published litera- 15. Linetsky FS, et al. (editors) Position Paper: Re- ture; however, a careful presentation of generative Injection Therapy (RIT): Effectiveness and the arguments on both sides would re- Appropriate Usage. The Florida Academy of Pain Care As a Beginning
quire publication of several books. The in- Medicine (FAPM). 2001. 12 pp.
Integrated or Blended Medicine is a con- tent here is to stimulate new and more 16. Miyoshi HR. 2001. Systemic Nonopioid Anal-gesics. Bonica's Management of Pain. 3rd Edition. cept that is gaining credence in recent correct approaches in fashioning a cus- Loeser, et al. (editors). Lippincott, Williams & Wilkins.
years. Clinics are including "integrated" tom solution for individual patients to at- Philadelphia. pp. 1667-81.
in their names. Understanding that the tempt cure or, at the very least, improve 17. Max MB and Gilron IH. Antidepressants, Muscle CAM portion of Integrated Medicine is their condition. I Relaxants, and N-Methyl-D-Asparatate Receptor An-tagonists. Bonica's Management of Pain. 3rd Edition. still in its infancy (in a scientific sense) log- Loeser, et al. (editors). Lippincott, Williams & Wilkins.
ically means that Integrated Medicine Dr. James Woessner holds a doctorate in bio- Philadelphia. 2001. pp. 1710-26.
must also be in its infancy. However, in the logical sciences in conjunction with a medical 18. Childers MK. Use of Alpha-2 Adrenergic Agonists opinion of the author, this is the direction degree. His professional medical training in- in Pain Management. Academic Information Systems.
2001. 128 pp. that is most likely to advance pain care, cludes neurology and physiatry. Dr. Woessner 19. Rowbothan MC and Petersen KL. Anticonvulsants now and in the future.
collects and analyzes data on a daily basis in and Local Anesthetic Drugs. In Loeser, et al. (eds.) his multidisciplinary practice; he frequently Bonica's Management of Pain. 3rd Edition. Lippincott, Synthesis, Summary and Conclusions
writes and lectures about pain and other sub- Williams & Wilkins. Philadelphia. 2001. pp. 1727-35.100 With this conceptual model of pain, we jects in Physical Medicine. Dr. Woessner may 20. Brookoff D. Chronic Pain: 1. A New Disease? have described a practical and more direct be contacted at Advanced Phys Med, 2615 Hospital Practice. The McGraw-Hill Companies. Web- way of analyzing the function of small pain 22nd St., Lubbock, TX 79410; 806-687- nerves. Deductively, depending on the 5420. [Editor's note: Dr. Woessner is in the 21. Knedlitscheck G. et al. Cyclic AMP response incells exposed to electric fields of different frequen- pattern and consistency of dysfunction, process of relocating to California and new con- cies and intensities. Radiation Environmental Bio- neuropathic and central pain can now be tact information will be made available by con- physics. 1994. 32:1-7.
analyzed in a more logical fashion. tacting Practical Pain Management.] 22. Zhou L, Ming L, and Jiang Q. [Protective effect of Medicine, particularly allopathic med- extract of folium ginkgo on repeated cerebral is-chemia-reperfusion injury] in Chinese. Zhongguo icine, has concentrated on curing noci- References
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Practical PAIN MANAGEMENT, Jan/Feb 2003
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