Pain Management in the 21st Century

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Chronic pain affects nearly 90 million Americans. It usually begins with a sports injury, car accident or health condition like migraines, diabetes, arthritis and cancer.  Chronic pain is different from the acute pain of stubbing your toe and often feels like burning, shooting, or shocking sensations.  The good news is that today’s pain specialists have sophisticated new treatments — from medications to advanced technologies — to provide chronic pain relief. 

 

Chronic pain can be classified as nociceptive or neuropathic pain.  In some cases (nociceptive pain) the body’s nervous system is working properly, relaying signals to the brain that there is an injury.  But in neuropathic pain the nervous system is not functioning properly.  There is no obvious source of pain but the body continues to tell the brain that injury is present.  Treatment is guided by the history of the pain, its intensity, duration, aggravating and relieving conditions.  The concept behind most interventional procedures for pain control is that there is a specific structure in the body with nerves of sensation that is generating the pain. Repair or replacement of the damaged structure may be all that is needed to bring relief. For neuropathic pain, specialists have multiple tools at their disposal – painkillers, injections, physical therapy, massage, heat therapy and use an individualized approach to attack symptoms from multiple angles.

 

Treatment		Comments
Heat	Infrared heat	Transmits the heat directly to the body through vibration of the water molecules present. Vasodilation– an increase in the diameter of the blood vessels, results in increased permeability allowing substances (oxygen , etc.) to pass more easily
	Heat sensation	Capsaicin- works by reducing transmission of a pain-relaying chemical called substance P to the brain
	Radiofrequency ablation	Pain relief lasts for a relatively long period, from three to six months.
Massage		Influences the activity of the musculoskeletal, circulatory, lymphatic, and nervous systems.
Exercise/ Physical Therapy		Reduces pain perception, Strong muscles help support and protect,   Stretching exercises lengthen shortened muscles which can pull and cause pain. (amount and form of exercise recommended for each individual will vary depending on area affected, amount of inflammation, how stable the joints are)
Percutaneous Electrical Nerve Stimulation (PENS)		Theorized that electrical stimulation of the nerve fibers close to a segment of the spinal cord blocks the pain signals from reaching the brain or that electrical stimulation reduces inflammation, swelling and relaxes muscle fibers by releasing endorphins in the brain which act like analgesics
Linear polarized near-infrared light		Suggested that PL-irradiation produces almost the same effect on shoulder joint range of motion as light exercise.
Radiofrequency ablation		Electrical current produced by a radio wave is used to heat-and-destroy a small area of nerve tissue
Accupuncture/ Sham acupuncture		evidence supports the claim that opioid peptides are released during acupuncture
Nutritional Modification		Certain foods (aspartame, methanol) contribute to nervous system damage, others modulate inflammation (omega fatty acids)

 

Modern knowledge of chemical pain signals — how the nervous system, including the spinal cord, interacts with the brain to create the sensation of pain– has led to methods for blocking or ‘confusing’ these signals.   

 

The brain can powerfully shape pain and we are just learning how to exploit its power.  Scientists are investigating the use of antidepressants, biofeedback and relaxation techniques. Wake Forest University School of Medicine researchers conducted a study that suggests that decreasing the expectation of pain can reduce both the pain-related brain activity and perception of pain intensity (Koyama).  Patients elsewhere have been taught to control body functions such as muscle tension, breathing, and heart rate — all of which help to reduce anxiety and stress reactions.  They can be taught to unlearn the pain response.

 

There is help available for chronic pain.  Seek treatment early when there is a better chance for success.

 

References

 

Binder, I..  Aktuelle Urol. 2008 May;39(3):205-14. The complexity of chronic pelvic pain exemplified by the condition currently called interstitial cystitis. Part 1: Background and basic principles.

Usha, Clin Drug Investig. 2004;24(6):353-63. Randomised, Double-Blind, Parallel, Placebo-Controlled Study of Oral Glucosamine, Methylsulfonylmethane and their Combination in Osteoarthritis

Muneshige H. J Rehabil Res Dev. 2006 Jul-Aug;43(4):565-72. Antinociceptive effect of linear polarized 0.6 to 1.6 microm irradiation of lumbar sympathetic ganglia in chronic constriction injury rats.

Demura, Shinichi Clinical Journal of Sport Medicine:Volume 16(4)July 2006pp 293-297

Haake M. Arch Intern Med. 2007 Sep 24;167(17):1892-8. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.

Koyama T, McHaffie JG, Laurienti PJ, Coghill RC. “The subjective experience of pain: Where expectations become reality.” Proceedings of the National Academy of Sciences, September 6, 2005, Vol.102, pp.12950-12955.

http://www.empireblue.com/wellchoice/medicalpolicies/guidelines/gl_pw_a053534.htm  accessed Mar 9, 2009

Martin Hoffman, MD. Medical College of Wisconsin. Department of Physical Medicine and Rehabilitation.  Exercise: a Natural Reliever for Chronic Low Back Pain  http://www.mcw.edu 

Little, P. Br J Sports Med. 2008 Dec;42(12):965-8. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain.

http://www.blatmanpainclinic.com/blat_articles_12.htm

Haake, M. Archives of Internal Medicine, Sept. 24, 2007; vol 167: pp 1892-1899. Heinz G. Endres, MD, Eric Manheimer, MS, research associate, Center for Integrative Medicine, University of Maryland School of Medicine, College Park.

Alternative vs. Integrative Medicine

Once upon a time individuals facing cancer felt they had to choose between one of two options- surgery and chemotherapy or alternative treatment.  But a new breed of medicine is emerging, one that bridges the gap between the two worlds and offers the best of each.  It’s called integrative medicine and world renowned medical centers such as Harvard and Stanford are pioneering training programs for the physician of the future.   

 

A Brief History

 

“Alternative medicine” was probably the first ‘other medicine’ term to gain popularity in the US and refers to treatments not taught in Western medical schools. This includes the use of vitamins, herbs and mind-body techniques. Essential to the alternative approach is a belief in the body’s ability to heal itself and that health is more than simply the absence of disease.  Increasing consumer use of alternative medicine in the early 1990’s led to the creation of the Office of Alternative medicine as part of the government’s National Institutes of Health.  This growing ‘new’ medicine gained popular media attention in the 1993 New England Journal of Medicine article by Harvard alumni David Eisenberg, MD.  The article estimated that in 1993, unconventional medicine users spent approximately $13.7 billion out of pocket on herbal remedies that are not covered by health insurance companies.    By 1997 out-of-pocket alternative medicine consumer spending had increased to $27 billion.  Eisenberg’s study also showed that most Americans used both conventional and alternative medicine, not one or the other.  The attempt to complement perceived weaknesses in each system was a revelation to the medical establishment and in 1998 the Office of Alternative Medicine was renamed the National Center for Complementary and Alternative Medicine (NCCAM).  The era of complementary medicine was born. 

 

By early 2000, larger medical centers began offering complementary medicine programs.  Patients receive the same type of care as before but have the opportunity to receive services such as acupuncture, yoga classes, art and music therapy programs under the guidance of the medical center.  But the evolution was not at an end.  Americans wondered whether these complementary approaches could benefit them not just as an add-on to the standard medical care, but as an integral part of their care.

 

There was a ‘great divide’ between the two medical systems due to the difference in approach and methodology.  Western trained physicians are not required to study botanical pharmacology or mind-body influences and Western medical schools do not offer alternative medicine certification.  For those practicing in either camp, the possibility that either medical practice has the ability to influence the effects of the other within the body, and the fact that practitioners are often unaware of each other was disturbing.  There was a need to better understand the interplay but more importantly, understand if/how it can benefit the patient.

 

Enter the Naturopath.  Naturopathic physicians are trained in one of four accredited medical colleges in the United States and practice integrative medicine using standard diagnostic techniques, pharmaceuticals and surgery when necessary.  The American Association of Naturopathic Physicians operates a searchable database making it quick to find licensed care. 

 

From a global point of view, integrative medicine is not new. Other developed nations such as France, Germany and Japan have practiced integrative medicine for decades.  The novelty is in the terms as defined by different cultures.  In Asia, traditional treatments (which would be considered alternative in the West) are still revered and passed down from mentor to student over thousands of years while conventional medicine (that taught by Western medical schools) is a comparatively new practice. 

 

What to expect in a complementary treatment program.

Current complementary medicine programs at institutional treatment centers provide complementary approaches as an option.  Surgery, radiation and chemotherapy are the standard of care for cancer.  Optional treatments may include nutritional support, naturopathic medicine, mind-body medicine, physical therapy, pain management and others.  Clinical trials investigating new treatments may be available (http://nccam.nih.gov/clinicaltrials/alltrials.htm) but the nature of clinical studies does not accommodate customization.

 

What to expect from an integrative medicine program.

In the integrative setting, practitioners collaborate in patient care- the entire team is fully aware of all treatment protocols.  Nutritional therapy, botanical preparations, mind-body medicine and physical therapies are coordinated into a single treatment plan. Examples of current integrative treatments include MRI-guided hyperthermia (heat treatment) in conjunction with radiation therapy of breast cancer,  and botanical adjuvants in standard chemotherapy.   

 

For future and current physicians, the University of Arizona has initiated training in integrative medicine, including a fellowship and distance learning program.  The reality is that any new therapy is an ‘alternative’ therapy until it is sufficiently proven by science to recommend its use. We are still in the process of testing the ‘new medicine’ but there is much to gain from what we already know.

 

Note: Advanced cancer presents special medical challenges.  Therefore, it should be addressed in a facility that has the capacity to diagnose and address complications that may arise. This is essential when considering a treatment center.

 

 

Resources:

 

National Center for Complementary and Alternative Medicine.  http://nccam.nih.gov/

 

Clinical Trials involving Complementary Medicine. 

http://nccam.nih.gov/clinicaltrials/alltrials.htm

 

Video Clips: Physicians and Scientists from Harvard Medical School, University of California Medical School, University of Maryland and others discuss integrative medicine.  http://thenewmedicine.org/professionals_and_educators

 

University of Maryland Searchable Database of Complementary and Alternative Medicine.    http://www.umm.edu/altmed/

 

American Association of Naturopathic Physicians. Physician locator. 

http://www.natruopathic.org

                                                        

Directory of Integrative Cancer Treatment Centers. 

http://www.DrDonnaDouglas.com/consultation.html