Education/CME

San Diego Pain Summit 2016


I’ve delayed writing about the San Diego Pain Summit to allow my thoughts to settle and to come up with a suitable distillation of the event. Good things take time to brew!

Impressions of San Diego – city of warmth and light, food and water and the sea… A lovely place to visit, and one that I would almost be happy to live in. But the setting was the least attractive aspect of this most excellent gathering of pain peeps. For me, first time attendee, it was like a gathering of the best of friends all in one place with plenty of time to geek out on pain science – and to put faces to names that I’m so familiar with that I feel like we’ve been friends for ever!

First off, hat tip to Rajam Roose who single-handedly organised this event. Without her vision and organisational strengths I would have missed a highlight of my career so far! Rajam was the most personable hostess, making sure I was picked up from the airport, fed and then dropped off at the hotel, taking photos to share on Facebook as I JUST GOT OFF THE PLANE after at 19 hour flight from New Zealand. Seriously, Rajam and her wonderful man (and assorted friends both furry and not) made my arrival welcoming and wonderful.

And this is probably one of the nicest things from the whole San Diego meeting – feeling welcomed, at home, and amongst friends. And this despite my being the only occupational therapist at the meeting! Come on, occupational therapists, you really need to get your collective acts into gear! The Pain Summit is probably the only meeting I’ve been to where everyone, no matter what background, whether body-oriented, brain-oriented, disability or function-oriented – is accepted, encouraged and enriched. Occupational therapists would feel right at home.

And now, to review the meeting itself. Well, to be honest, the meeting WAS about the people. The discussions had between different professionals from differing backgrounds and theoretical orientations, all focused on learning more about pain and how to better help people who experience pain. While the speakers were outstanding, without the community discussions, both on and off-line, I think this meeting would be much like any other. The hallmark is that the people who attend are committed, passionate and really think about the meaning of new research and how they can apply it.

I’ve talked about a community of practice before. A community of practice is a group of people who have developed a commonality in how they tackle their work. Where theory and practice are connected in the most intimate ways. Where each piece of evidence is examined in the light of the question ALL research should be evaluated against: So what? So what does this mean for ME? So what can I use from this? So what does it mean that this – and this – are both true? So what questions do I need to ask myself?

The Pain Summit is a place where choices don’t have to be made. It’s designed so that people can attend every session, rather than having to choose a stream (and miss out on the other stream). And one where ethics hold out over money-making. Rajam doesn’t want to have to take sponsorship if this means the Summit has to compromise on any information presented. It’s designed so that clinicians can meet the presenters and talk. Where presenters engage with one another and with the attendees.

The most profound talks for me personally were Lehman’s take on biomechanics – when it applies, and when it doesn’t. Argued from a biomechanical perspective. And Benedetti’s talk on placebo and the mechanisms that skew randomised controlled trials of new pharmacological and surgical agents (yes, I know placebo is a thing affecting ALL treatments, but much more difficult to study in nonpharmacological approaches). I was saddened to hear that yes, if we persist in using the WHO Analgesic Ladder, we may be inadvertently doing harm because repeated ineffective treatments can establish negative expectancies from ALL treatments – hence my take on identifying the pain mechanisms involved and providing targeted therapy specific to those mechanisms rather than a “multimodal” approach that may not provide much at all. The argument Benedetti made was that medications that don’t work create a learning effect in the recipient, reducing the potential for subsequent treatments to be effective. So if you have fibromyalgia, probably the archetypal “central sensitisation” pain problem, treating it with NSAIDs and codeine and other opiates isn’t likely to do anything wonderful – why not begin with the tricyclic antidepressants and gapabentin/pregabalin first?

I also loved Alison Sim’s work on presenting CBT for pain, clear, precise – and engaging. And yes, anyone can integrate it into daily practice.  The appetite for “psychological” approaches amongst this largely hands-on audience was amazing. Kevin Vowles impressive presentation on the futility of many approaches to “get rid of pain” and the usefulness of values-based action (using ACT) (and his wonderful workshop on ACT) made my day. Between them and Sandy Hilton’s discussion of ways to work with people who have pelvic pain, and I began to feel like this group of clinicians really knows that PEOPLE experience pain, not limbs or body parts. And to help PEOPLE we need to BE people – human connectedness is so important.

There were many other talks, but these were the ones that really stood out for me. I’m now impatiently waiting for the video recordings so I can relive the moments of the Pain Summit and pick up on the many, many details of talks I haven’t mentioned. I haven’t mentioned them not because they weren’t great, but because the ones I’ve listed resonated particularly with me in my own orientation.

Next year – will you be there? I hope so – I’ll be there, and I’m looking forward to being amongst friends again – and keeping that discussion going on Facebook, Twitter, SomaSimple in between.

You are unique, and if that is not fulfilled, then something has been lost: Martha Graham


In an era in healthcare where administrators prize standardisation, algorithms and consistency, it’s no wonder that in chronic pain management there are concerted efforts to make a standard treatment recipe to suit everyone. After all, there are common things that people living with pain need: accurate information about pain, accurate information about tissues and how they contribute to pain, assurance that pain doesn’t mean ongoing damage, and being introduced to some safe movements that don’t threaten an already agitated nervous system. There’s even a call for clinicians to use a kind of curriculum to make sure all the important bits are covered based on the individual’s presentation. This is valuable stuff!

But, I think standardisation* is both an admirable and a futile effort. Admirable because we know there are so many clinicians and patients who don’t get told much  of this information. Admirable because it would be great to know that once given, this information should make a difference to the person living with pain. Admirable because it’s easier to remember a “standard” list of topics, or a standard management approach than to generate a fresh new one every time a person comes in to see you. But I think a standardised approach (used unthinkingly) might not be the most efficient way, it could almost be futile, and here’s why.

*(note: not the curriculum for pain education, but the notion of a standard list of topics that every person with pain should have covered)

I’m a nerd. That’s right, when I get on a topic I love, I can talk for hours! I have seen the eye rolls, and that subtle slump that tells me that I’ve gone on too long. I think there’s a very fine line between being enthusiastic and being too intense, particularly when it’s a topic I love but maybe the other person is less enthralled with. I know I’m not alone in this enthusiasm (thank goodness!) but I also know that I need to be aware of all those cues that tell me when someone has had enough and I’m boring them. If I want to do more than lecture, I need to go about my conversations in a different way.  I have to actually converse not harangue!

Conversations, especially where one person is knowledgeable about a subject and the other isn’t, are really guided discoveries. A guided discovery is where one person asks a question and the other person, who knows the answers, is able to answer. The questioner listens because he or she wants to find out. Various skills underpin conversations – mirroring body language, use of gaze (looking at the person, looking away), using metaphors and those little “listening cues” like “uhuh” or “mmmm” or “tell me more”. The thing about conversations is that although one person is finding out about the other, in fact most times both parties will learn something new.

We’d expect the person asking the questions to learn something new, but the person responding? How do they learn something new? There’s quite a large body of research that considers conversation to be one of the main ways humans develop meaning, and that these meanings are then reflected in the way we perceive events and act on them (Strong, 1999). In other words, as we converse with one another we develop a shared understanding of the subject under discussion – or at least it’s possible to do so.

This view is part of a social constructivist view of reality.  Strong’s paper states that people living with chronic pain experience suffering when “chronic pain sufferers and others are engaged in conversations that yield no differences in meanings for the participants” (Strong, 1999, p. 39). In other words, when one person is not heard, or the conversations they have with others don’t influence the beliefs or meanings they have, the conversations themselves contribute to suffering.

It’s not hard to see that if one partner in the conversation isn’t really listening; or if the questions being asked are only done to confirm a prior belief; or if the person answering doesn’t think the other is listening – well, neither person will change his or her understanding. And I think this is what we risk if we use a standardised way to provide information to people.

I can see that instead of being a conversation in which both parties learn, “educating” could become an opportunity for one person to lecture the other. Now I know this isn’t the intention of pain neurophysiology education. I know that it’s intended to be conducted within the framework of genuinely wanting to help the person living with pain view their pain as less threatening and less mysterious.

I said before that I think standardising a “pain education” for people living with pain might be futile. This is why: when each person has a unique understanding of their body, their pain and their life, and when they’ve had a unique pathway to getting to see a clinician, they’ve probably also had any number of unique conversations in which their understanding of their pain has been changed. They’ve taken a bit here, and a bit there. A piece of this and a dab of that. And then they’ve infused this with their own experiences and arrived at their own theory for why they have pain. Each one of those thoughts and beliefs and attitudes needs to be revisited in the light of new information. This is not something that will shift with just one “info dump”.

What I’ve learned from motivational interviewing and case formulation (thanks psychology!) is that until the person is ready to hear what we have to say, they’ll pick up on the parts of what we say that they want to hear. What this means is that we need to give them the respect they deserve for making their own theory for their pain, and we need to listen to what it is and how they’ve developed it. It makes sense to them. And we need to ask for permission to introduce a new idea. If we jump right on in there without being given permission I know how that will go down! In a few cases the person will be absolutely fine with it: they were ready to hear something new. But in many cases, we’ll be generating resistance because we’re challenging something the person has learned for him or herself.

I think we also need to recognise that people pick and choose the bits of information that resonate for them. This means their understanding of pain is unique to them. We know that reviewing existing knowledge in light of new information is a really good way for students to develop a deep understanding of their subject matter – the same occurs for people learning about their pain. By gently guiding people through both their current understanding, and then through a combination of information and experience, they will draw their own conclusions about what this new material means. Our “education” needs to be a guided discovery together with the person so they can make sense of their experience in the light of new information.

Some resources for guided discovery: – teaching physical education

Socratic questioning – Padesky

Priory – guided therapy

Psi – Balancing thoughts

Strong, Tom. (1999). Macro- and micro-conversation in conspiring with chronic pain. Journal of Systemic Therapies, 18(3), 37-50.

Those who expect moments of change to be comfortable and free of conflict have not learned their history ~ Joan Wallach Scott


I’ve been touring North America – Chicago, Toronto, Edmonton and Vancouver. As I’ve toured I’ve been listening to the stories of change and insight as different professions review their contributions to effective pain treatment. Some things change, some things stay the same – but as the quote above indicates, change isn’t comfortable nor free of conflict.

What have I found in my travels?

There’s a great deal to be proud of in our approaches to helping people who live with pain. Allied health practitioners of various backgrounds have adopted and adapted to the discoveries about how people experience and deal with their experience of pain. There’s been enormous change in our views of pain as neither a form of mental illness (or malingering, or imagination, or even simply weakness of spirit), nor a lifelong static state. Allied health practitioners of every kind know that they can contribute to helping people make sense of their pain, perhaps change their experience and reduce the distress and disability that living with pain can bring.

Disturbingly, though, I heard the exact same issues as those I face in New Zealand, when it comes to unrest and disquiet about competence, scope, and funding for effective treatments.

Disquiet because some of the different professions lay claim to certain areas of practice as “theirs”. Disquiet because there are attempts to limit access to learning about aspects of pain that are integral to the experience and management of pain. Concerns that some clinicians might be overstepping their scope when they begin to develop skills in, most notably, psychosocial aspects of our experience of pain. And disproportionate funding given to short-term (primarily) biomedical interventions without a consistent or even logical argument for similar funding levels to be applied to allied health approaches. Or worse – funding given to those working in a single-discipline approach, and loss of funding (or funding not even considered for) approaches where teamwork is a critical part of the treatment.

As a somewhat renegade occupational therapist with a MSc in psychology, PhD in health sciences, and great interest in psychosocial aspects of pain, I know that I don’t sit especially comfortably in one little box. And it was SO refreshing to find that I’m not alone in this. As allied health professionals develop knowledge and skills in a biopsychosocial and neurobiologically sophisticated model of pain, it becomes increasingly difficult to distinguish between the practice of good occupational therapists, physiotherapists, massage therapists, psychologists, nurses and social workers when working with people who live with pain.

Our aims are the same: we want to help people live good lives despite experiencing pain. Some of the ways we ALL do this are to help people reconceptualise pain as something that is not fixed but can be influenced by reducing the threat value of the experience within the context of what we view as important.

We ALL draw on learning theories, influencing beliefs and attitudes, consider contingencies and work at reducing the relationship between experiencing something inherently unpleasant and avoiding that experience.

We ALL help people set goals, work hard to achieve them, use movement and activity to help pursue what is valued and deal effectively with what gets in the way of this.

We ALL use motivational approaches, we ALL consider personal values and choices, we ALL want the people we work with to have the freedom to choose personally-valued goals and outcomes.

We ALL draw freely on the published scientific literature across all the branches of pain research – biological, psychological, and to a lesser extent, sociological. (I’d love to see far more emphasis on the social as I’m sure regular readers know!).

It confuses and perplexes me that each one of our professional groups has, at times, criticised other professions for failing to address or consider the aspects of pain experience that our particular group sees as critical. But what really perplexes me is that once another profession begins to take up the challenge of adopting and integrating learning from “outside” their original knowledge base, some people turn right around and begin to criticise that group for “working out of scope”. It does not make sense.

A discussion that I think needs to begin is to consider the merit of a specialist “certification” if you like, for those people who have taken time to learn about pain in-depth, and who no longer fit as comfortably within their original profession as they once did. As I saw so often in my travels, when we get beyond the simplistic level of learning about pain as a biopsychosocial experience we begin to recognise that the way we work with people changes over time to become so much more similar than dissimilar that our professional disciplinary approaches seem to fade away.

I know that in the years since my original training and graduation as an occupational therapist (waaaay back in 1983) I’ve done so much more learning and development that what I do now is so very different from what I did then. I’m still essentially interested in helping people do what is important in their lives. Doing, or occupation, is integral to my practice. The ways I help people achieve this (thus reducing distress and disability) has changed but my “domain of concern” (old-fashioned language for “what I’m interested in”) is still occupation, or the things people want and need to do in daily life.

The obstacles to participating in occupations might be addressed in slightly different ways, but I draw on the same fields of knowledge that I drew on in 1983. Just as I learned then that biomechanical, kinesiological, anatomical, biological, psychological, social, anthropological – and the rest – ways of understanding human behaviour informed the way I work with people, I STILL draw on those same fields of knowledge. The first three fields might have less influence now than I thought they did when I first started working in pain management, but they all contribute.

So here’s the thing: if there is so much our different professions have in common with one another, is it time for allied health professionals to work in a united way to demonstrate just how significant our contribution is to the health and wellbeing of people living with pain? Is it time to trust one another just a little more and stop the infighting as to who is working “in” or “out” of scope? Isn’t it time we looked to the people we work with and for, and focused a little more on sharing our expertise with one another? Shouldn’t we trust that if we’re interested in what works well for the people we want to help, we’ll develop effective knowledge and skills rather than thinking, like Gollum “It’s mine! It’s my preciousssssss!”

I truly thing we can do a much more effective job if we remember that while we let go of some things that we think of as “ours” we might have made just a little room to add some new skills to our own repertoire? And perhaps that change might happen more smoothly if we were more accepting of the need to let go some control and trust a little more.

My North American Tour!! #Bronnie2015


It’s fast coming up – my wonderful North American tour!! Thanks to some amazing friends who have organised the details, I’m going to be in North America from the end of May to mid-June at the following places:

11 June – one day workshop on graded exposure!
13/14 June
What am I doing?
This is a two-day workshop on integrating biopsychosocial factors into clinical assessment, clinical reasoning and treatment planning. It’s about taking pain management from the clinic into the real world. It’s a time to learn more about the practical aspects of integrating these messy concepts – without breaching your scope of practice!
By the end of the two days you’ll have some tools you can use on Monday, gained confidence and had fun.
Come and join me and the fabulous team who have done all the arranging for these workshops!

Mike “KnowPain” Stewart is coming to New Zealand!


I’m very proud to announce that Mike Stewart, Clinical Specialist Physiotherapist in pain management for East Kent Hospitals University Foundation NHS Trust is coming to New Zealand to take three of his award winning Know Pain Workshops for allied health professionals.

Mike is widely known amongst the pain clinicians, particularly physiotherapists on social media, and is a keen advocate of therapeutic neuroscience education (TNE) as a means for improving health outcomes for people with chronic pain. Therapeutic neuroscience education is a key component of the Moseley and Butler Explain Pain approach to pain management, and there have been numerous research papers demonstrating effectiveness of this approach.

Mike is coming to New Zealand (Auckland, Wellington and Christchurch) at the end of April, beginning of May 2015.

This is his website – http://knowpain.co.uk/

And here’s what you can expect:

CaptureNOW is your chance to register for this workshop in Christchurch –

2nd & 3rd May 2015
Department of Orthopaedic Surgery &
Musculoskeletal Medicine
University of Otago
Christchurch, NZ

Workshops are also being held in Auckland and Wellington.

For more details, contact Dr Bronnie Lennox Thompson, ph 64-3-364-1086 or 027 270 4225

For even more details, contact Paul Lagerman (aka The Naked Physio!) – thenakedphysio.com

These workshops are supported by AUT University and University of Otago.

AUT LogoUniversity of Otago - Te Whare Wānanga o Otāgo

Fabulous FREE pain education resource from Cardiff University


It’s amazing what you find on the interwebs. Thanks to Pete Moore from Pain Toolkit –you can find him on Twitter as @paintoolkit2 – I’ve been introduced to Cardiff University’s amazing Pain Community Centre. This is a site developed by pain educators and clinicians to provide authoritative and practical information on a wide range of pain topics. FREE CPD, a chance to chat amongst others with the same inclination, clear video recordings, a list of events in the UK, and a set of “Pain  Toolkits” on topics such as migraine, central post-stroke pain, general management of osteoarthritic pain and so on. This is by far the most comprehensive and well-organised site that I’ve stumbled on in a long time. Well worth the visit (and you’ll probably lose some hours as well!). Oh, and Pain Community Centre is also on Twitter as @paincommunity

Book review: 2nd Edition of Pain: A textbook for health professionals


I’m an educator, and always on the lookout for a good textbook that summarises and presents up-to-date material in a format that’s easy to read and yet comprehensive. The first edition of this book was a great one and I’ve been hoping a new edition would come out – well, the wait was worth it!

Pain: A textbook for health professionals is edited by Hubert van Griensven, Jenny Strong and Anita M Unruh, published by Churchill Livingstone (Elsevier), and released in November 2013. It’s a whole lot of new material wrapped up in a shiny new cover, over 400 pages of fully-referenced patient-centred pain geekery.

What makes this book different from many is the focus on functional outcomes for people with pain, and on the patient’s voice. The book opens with a chapter on “what is pain” from the perspectives of the person, the interprofessional team, the physician, nurse, psychologist, physiotherapist and occupational therapist – and other providers. The “textbook” nature of the book means there are reflective exercises scattered throughout in which you are invited to reflect on your experiences and perspectives, also clear objectives for each chapter, and study questions at the end of many chapters. This is great, because it can be so easy to read with the head and not with the heart.

What’s in the book?

It opens with “what is pain”, the patient’s voice and social determinants of pain as the first three chapters. This is again unusual, because most texts open with neurobiology or models of pain, sometimes forgetting that it is people who experience pain, while neurobiology only transmits information.  It also reminds us that for us to know anything about what it is like to have pain, both the person with pain and the onlooker need to communicate – to encode, transmit and decode behavioural components to convey the pain experience to one another. And here is where so many problems begin! Because if either party fails to recognise the signals, communication is faulty and we have assumptions and opportunities for misinterpretation that can then lead to increased distress and disability.

The first section of the book then covers the psychology of pain, models of pain, neuroanatomy, and neurophysiology of pain. What I like about these chapters is their clarity and the level of detail which is not overwhelming but remains accurate (to the extent we can be!), and is well-illustrated for those of us who like pictures for learning.  The level at which it’s written is for those with a reasonable familiarity with anatomy and physiology, but it’s not dumbed down, and quickly gets into the level of detail needed to understand many of the latest publications in the area.

The second section relates to assessment and management, and its in this section (which has 10 chapters) that this book really shines. It incorporates biomedical, psychological, functional and complementary modalities, including manual therapy and workplace rehabilitation. Not something you’ll often see in a textbook on pain! I particularly enjoyed the chapter on neuropathic pain and complex regional pain syndrome, and it’s great to see discussion of newer modalities like mirror therapy, laterality training and graded motor imagery.

The third section is called “special issues” and has chapters on pain education for health professionals, pain in childhood and older adults, cancer pain and spinal pain, and then turns to some rather neglected issues: rehabilitation and ICF, life role participation, the law, psychiatric problems, and acute pain.  These are remarkable because they consider the impact of having pain on the individual’s identity and life even if the pain subsides. The focus of management is not simply on pain reduction, but on how an individual becomes well again.

What I like about this book:

It’s comprehensive, written by experts in the field, clearly written, and considers the person with pain and the effect pain has on identity and engaging in occupation. The index and referencing is great, nice clear illustrations, lots of aids to learning including the reflections and end of chapter study questions. The price is reasonable and I could see this book being used as a textbook in pain courses (I may even adopt it for my students!).

What I like less about this book:

For a textbook, the cover (I have a soft cover) is a bit light, and I am worried about the spine breaking down if it’s used the way I use textbooks – opened out, copied so I can highlight pages, pages marked with post-it notes, and used in a busy office space where someone else could “borrow” it! It’s definitely covetable, and that’s always a problem for me (I never remember to get them back!).

The price in New Zealand was about $85.00. I think that’s pretty good given the cost of many other textbooks. This book would sit well on anyone’s shelf, but especially for people wanting a good overview of pain and pain management, and anyone entering pain management practice.

Overall:

A very useable, readable textbook on pain for clinicians who want a thorough introduction to pain management, or to refresh and update knowledge without wading through all the journals.

And for people who would like a patient-oriented book: I’ve reviewed Dr Steven Richeimer’s book Confronting chronic pain in my Healthskills4Pain blog

SUGAR-COATED NERVES: THE PSEUDO-SCIENCE OF NEURAL PROLOTHERAPY


It’s not often I have guest bloggers on Healthskills, but today I post an important article by Dr John Quintner, who writes about prolotherapy. If you haven’t heard of it, it involves being injected with a substance that creates local inflammation. Read on – it’s not something I’ll be doing any time soon.

The human understanding when it has once adopted an opinion draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects or despises, or else – by some distinction sets aside and rejects, in order that by this great and pernicious determination the authority of its former conclusion may remain inviolate.

[Francis Bacon (1620) from Novum Organum, Book 1, Aphorism XLVI.]

 

Introduction

The latest fads from the shadowy world of pseudo-science have always been quick to take off. For those who are keen on approaching pain sufferers with their sharp needles, the invention of Neural Prolotherapy by Dr John Lyftogt, of Christchurch in New Zealand, must have come as a godsend. A quick search on the Internet reveals that this invention is being taken seriously by a number of health practitioners who one might have expected to have known better than to accept it so uncritically.

 

The claims for Neural Prolotherapy

“Prolo-” is short for proliferation and derives from the Latin “to regenerate or rebuild”. Prolotherapy with injectable substances that are being acclaimed as growth factors is now the subject of intensive research. But Dr Lyftogt favours hypertonic sugar injections.

 

Here are some remarkable extracts from his website (http://www.doctorliftoff.co.nz/):

 

After the success of Neural Prolotherapy with Achilles tendonitis other persistent painful conditions of the neck, back, shoulders, elbows, wrists, knees, ankles and feet have been effectively treated by targeting the local inflamed superficial nerves with micro-injections of low dose Glucose.”

 

Comment: there have been no properly conducted clinical trials of Neural Prolotherapy.

 

“More recently Dr Lyftogt has developed effective neural prolotherapy treatment protocols for Migraine. ‘Fibromyalgia,’ CRPS, compartment syndrome and other difficult to treat persistent painful conditions.”

 

Comment: Again, no clinical trials have been conducted. The evidence is purely anecdotal and subject to all forms of bias.

 

“Neural prolotherapy is an effective novel and evolving treatment for non-malignant persistent pain, based on sound neuroscientific principles.”

 

“Subcutaneous prolotherapy with a series of percutaneous near nerve injections has been shown to be an effective treatment for a variety of recalcitrant painful conditions caused by prolonged neurogenic inflammation.”

 

Comment: This is the logical fallacy called circular argument: the conclusion is assumed before the evidence is presented. Dr Lyftogt offers no evidence that these conditions are associated with “prolonged neurogenic inflammation”.

 

The “sound neuroscientific principles”

Dr Lyftogt targets the “guilty” superficial nerves by injecting 5% Mannitol or 5% dextrose and thereby claims to modulate the neurogenic inflammation that he believes is responsible for “neuropathic pain”. He refers to the work of a highly regarded authority:

 

“Quintessential to the working hypothesis that subcutaneous prolotherapy treats prolonged pathological neurogenic inflammation is the work by Douglas W Zochodne from the Neuroscientific Research Unit at Calgary University.” [1]

 

When contacted by the author, Professor Zochodne replied: I can indicate that I have no interest in it, have not endorsed it or plan to endorse it and am disappointed our work would be quoted for something without evidence.

 

But there is more!

 

“The author hypothesizes that subcutaneous prolotherapy injections of hypertonic glucose and 0.1% lignocaine induce apoptosis of proliferating peptidergic noceffectors (i.e. SP and CGRP) and neovessels by reducing VEGF (vascular endothelial growth factor) levels and restoring “effective repair processes” with reduction of pain.” [2]

 

Comment: In this author’s opinion, this is pure speculation.

 

On his website and in a recent email to Associate-Professor Geoff Bove, a world leader in experimental studies of nervi nervorum (“the nerves of the nerves”), Dr Lyftogt claims that his injections target specific receptors (TRPV1) present on the nervi nervorum.

 

“The very small nerve fibers, innervating the nerve trunk, identified as unmyelinated C-fibers or ‘Nervi Nervorum’ are responsible for pain and swelling of the protective sheath of the nerve trunk. This was already demonstrated 125 years ago by Professor John Marshall from London and called neuralgia. It is now called ‘neurogenic inflammation’.”

 

Comment: Dr Marshall was in fact advocating “nerve stretching” in his Bradshaw Lecture given in London. Fortunately, this form of treatment has long been abandoned as being both ineffective and potentially dangerous.

 

Dr Bove made the following personal response to Dr Lyftogt in relation to his facile incrimination of the nervi nervorum:

 

“Dextrose does not do anything to TRPV1 receptors, and it is certainly not selective for abnormal ones (and there is no knowledge that those exist). You are not targeting nervi nervorum other than in your mind; they are few and far between on the small peripheral nerves, and maybe nonexistent. 

Regardless, you have nothing to offer regarding the injected dextrose reducing their function and thus reducing neurogenic inflammation, or reducing neurogenic inflammation at all. 

 

The bottom line

According to Dr Lyftogt: “The growing scientific evidence supporting the view that neuropathic pain syndromes are caused by unremitting peripheral neurogenic inflammation involving the autonomic and sensory nerves may lead to renewed interest in prolotherapy and neural therapy as these treatments are effective and seem to target the PNS.” [3]

 

However, Dr Lyftogt has yet to demonstrate the presence of the unremitting (enhanced) neurogenic inflammation that he claims to have identified and treated with his sugar injectates.

 

Conclusion

The question as to the efficacy of Neural Prolotherapy, as practiced and taught around the world by Dr Lyftogt, is outside the scope of this article. There are no published trials upon which to base any firm conclusions.

 

Anecdotally, there may be face validity for this treatment but to date there has been no discussion of placebo effect, observer bias, expectation bias, reversion to the mean of the conditions being treated etc.

 

But what is abundantly clear is that published animal experimental research by leading neurobiologists Professor Douglas Zochodne and Associate-Professor Geoffrey Bove does NOT in any way support Dr Lyftogt’s hypothesis. This should be the end of the story but I suspect that the aphorism by Francis Bacon is as true today as it was over 400 years ago. All we can do is hope that good science will triumph over its rival.

 

Author: Dr John Quintner, Physician in Rheumatology and Pain Medicine

Dr Quintner accepts full responsibility for the content and opinions expressed in this article.

 

References

1. Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Australasian Musculoskeletal Medicine November, 2007: 83-85.

 

2. Lyftogt J. Prolotherapy for recalcitrant lumbago. Australasian Musculoskeletal Medicine May 2008: 18-20.

 

3. Lyftogt J. Pain conundrums: which hypothesis? Australasian Musculoskeletal Medicine November 2008: 72-7

A new year, a fresh beginning


It has been a long time since I last posted actively on this blog. This is because, over the last year, I have been writing my PhD thesis – and although I’m not yet completely finished, I’m very close. This means I’m ready to roll out the weekly blog posts again!

For people who are not familiar with my blog, the blog emerged as one way I could cope with, and rehabilitate from, a so-called “mild” traumatic brain injury – aka post-concussion syndrome.

My aim was, and still is, to provide clinicians with research-based information about chronic pain, and how to live well with it. Truly, to help those who help people to develop Health Skills.

I’m definitely a pain geek. I love reading the research literature. At the same time, I know that a good deal of research is hidden behind paywall subscriptions to j0urnals; many clinicians don’t have time to read through the enormous range of journals that are available; and some research doesn’t seem particularly relevant to daily clinical practice.

My mission, and I’ve chosen to accept it, is to do some of the work for you. I can access many journals as part of my academic work (I’m a Senior Lecturer in pain in the Department of Orthopaedic Surgery & Musculoskeletal Medicine, University of Otago, Christchurch, NZ). I have to read this stuff, and because I teach, research and work clinically, I need to work out the relevance of research in my own mind to make any sense of it.

I’ll carry on posting brief summaries of good research from peer-reviewed journals. I’ll also consider the clinical implications – or at least I’ll ponder them, whether I arrive at any conclusions is probably a moot point. At the very least I hope I’ll provoke some questions in your mind about what the research means for you in your clinical practice.

If you’re a person who has chronic pain, please note that this blog isn’t intended to provide you with answers to your personal situation. I don’t know you, and couldn’t possibly work out whether you should, or shouldn’t, apply anything to your situation. For what it’s worth, I do have chronic pain (fibromyalgia), but I don’t do this kind of work as some sort of personal crusade. I just think that anyone who has chronic pain deserves really good, open and honest pain management, and my little part is to make some of the research more widely available than it is otherwise. If you’ve found The Answer – fantastic! If you’ve got The Clinician – great! But what probably works for you, may not work for anyone else, and I won’t promote it unless it’s subject to systematic scientific examination.

Finally, I’m not into arguing with dogmatism, mystical beliefs, superstition or even engaging in terribly much argument. It rarely does anything for anyone, and wastes my energy. I’m a scientist – I have a Master of Science, and nearly a PhD. I’m not going to pretend tolerance of appeals to etheric energies or other wafty notions. With that in mind, I do love interacting with people who have genuine interest in understanding what this thing called pain really is, and how we can all help people live more fully despite having to deal with it long-term.

Catastrophising and Pain (ii)


ResearchBlogging.org
What are some of the indications that someone tends to catastrophise about their pain? How do we know? Do we have to use a questionnaire? Is it really my job to know about this if I’m not a psychologist – and what do I do about it?

These are the kinds of questions that have been posed to me as I’ve explored the topic of catastrophising, and I propose to answer the last question in my next post (sorry to keep stringing you along like this – I think many may know my take on that already!).

I work in a wonderful interdisciplinary team setting, in a centre where everyone who attends the Centre gets to complete a set of psychometrically sound questionnaires that all of the team are encouraged to use and interpret, so any of the team can be confident about identifying and working with a patient who catastrophises. BUT I know that many clinicians work alone, or work in a team that functions in a multidisciplinary way, and where patients don’t routinely complete questionnaires.

So, what can solo, primary care clinicians do?

As I mentioned before, questionnaires are not X-rays of the mind – they simply organise how information is obtained, and allow us to compare the responses from one person with the responses from many others so we can decide how similar or different this one person is. In other words, using a questionnaire is just another strategy to help assess where a person is at.

It’s possible and sometimes really helpful to just ask
. With some proviso’s of course – asking the right questions and not just asking but also observing behaviour and putting this information together in some form of clinical reasoning about what is going on, and what this might mean for treatment.

Even if you decide to use a questionnaire (and maybe the Pain Catastrophising Scale is a useful choice), it’s important to decide who to give it to, when to give it, and most importantly, how to interpret it because numbers just don’t mean anything on their own – not even percentage change over time tells us very much if we don’t know the meaning of the domains they are representing.

Here’s another Healthskills Advice for NonPsychologists list on questionnaires and catastrophising!

  1. Some indications for considering the use of a measure of catastrophising are people who present as highly anxious or distressed about their pain, who describe their pain in dramatic metaphors or say things like “my back will snap” or “my bones and nerves are being ground away”, who say things like “I can’t stand it any more” or “it’s terrible and it can’t go on”, or who are fearful they will “end up in a wheelchair” for example.  Particularly people who believe that moving will “do damage”, and those who seem completely helpless when they have pain “there’s nothing I can do when I have pain”.
  2. It’s probably not so helpful to administer a questionnaire for catastrophising in someone who is seeing you with acute pain (first episode, within the first two or three weeks), but more useful to give it to someone who has had their pain for six weeks or more (sub-acute), who has had episodes of pain that have lasted more than six weeks before and had a slow recovery.
  3. In primary care settings most people won’t demonstrate catastrophising – but there is some research that suggests up to 25% of people with acute pain hold catastrophic beliefs (Ciccone, Chandler & Kline, 2010), and this finding was in young, fit military people!  Clearly not everyone who has catastrophic beliefs when they have acute pain go on to develop long-term disability, but the risks are higher, so a screening assessment like the Orebro Musculoskeletal Pain Questionnaire might be useful for routine administration in acute, primary care settings.
  4. It’s not very useful to use an English language questionnaire with someone who doesn’t speak English well – see if there is a questionnaire in that person’s language instead.  Be wary of using a translator to help someone answer a questionnaire, because this can lead to unintended errors and invalidate scoring.  The same applies if the person has limited comprehension.
  5. Make sure you read and understand the questionnaire, what it measures, how it’s interpreted, what the reference or normative group is, and how to score it.  If you don’t know these things, you’d be far better off not to use the questionnaire! Kthx.
  6. If you’re going to ask about catastrophising, you can ask things like
    • What goes through your mind when your pain gets bad?
    • What do you think is happening then?
    • What images go through your mind when you’re really sore?
    • What can you do to help yourself when your pain is really bad?
    • What do you think will happen in the future if your pain gets bad?
    • What do you think is going on in your body when you’re really sore?
    • What can you do to get by when your pain is bad?

Can you tell that this post is not the last in this series? But wait, there’s more!  Come on back for more, and don’t forget to comment (they’re always welcome).
Ciccone DS, Chandler HK, & Kline A (2010). Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops. The Clinical journal of pain, 26 (8), 712-21 PMID: 20664336