When chronic pain is there before surgery

People with chronic pain present a special risk for surgeons, anaesthetists, nurses and the rehabilitation team working with them after surgery.  Surgery is, after all, “planned trauma”, and a sensitive nervous system is going to be even more sensitive after a surgical insult – even when that surgery is intended to reduce pain.

One of the most cost-effective, and clinically-effective treatments for osteoarthritic hips and knees is to simply replace the offending joint with a shiny new one.

In one major New Zealand hospital, people are referred to the Orthopaedic Department by their GP or family doctor. The referral is screened for suitability, the individual is asked to see a physiotherapist for a physical performance test and to complete a set of questionnaires about function and pain. The results from this testing is returned to the Orthopaedic Surgery triage team who review the findings, and, depending on the level of disability, determine whether the person should then proceed to see a surgeon. Once a surgeon has reviewed the person in a face-to-face clinical consultation, if suitable for surgery, they may be placed on a waiting list and eventually have their surgery.

Surgeons like to be successful, and they try to identify those people who will do well with a joint replacement, but despite this, every year there are a good number of people who don’t get the result they’d hoped for. For some, the result might be a very slow recovery, some may do well then end up with a “squeaky” or “clunky” joint, some have an infection or the prosthesis doesn’t sit correctly or something goes awry and they need to have a revision of the joint.

In the case of knee joint replacements, the number one reason for surgical revision is ongoing pain. Now there are a number of reasons for this: the joint capsule is pulled and pushed around to get the replacement joint into place; there are a good many muscles to manipulate, the joint must be moved consistently after surgery so that range of movement is maintained, and so on.

But one reason could be because a group of patients receiving a joint replacement have additional risk factors for post-operative pain that remains unrecognised.

In a large study in Michigan, people about to undergo hip or knee replacement surgery were asked to complete a range of questionnaires – in this study, one of the items included in the questionnaires was the Michigan Body Map. This is a one-sided body map in which the respondent is asked to tick as many boxes as needed (up to 35) to identify where pain that has lasted longer than 3 months is experienced. The researchers used the responses from this questionnaire to calculate a Widespread Pain Index from the 19 specific body areas identified by the 2011 ACR suvey criteria for fibromyalgia. Additionally, they used the scores from a Symptom Severity Scale, added to the WPI and identified those with a score of 13 or more, which is thought to denote those with fibromyalgia from those without. Purists will note that this is not a typical methodology for diagnosing fibromyalgia, but it seems a pragmatic way to identify those with a greater potential for having this diagnosis than not.

Because people with fibromyalgia paradoxically have more endogenous opioids in their body, therefore fewer opioid receptors available to bind to any additional prescribed opioids, people with fibromyalgia need considerably greater doses of opioid than those without this diagnosis. In this study, therefore, the researchers monitored the use of opioids pre and post-operatively.

After some serious statistical work, the group found that younger people, anaesthetic technique, having a total knee replacement (as opposed to a total hip replacement), and longer stays were more likely to use a greater amount of opioid. And, more importantly, the scores obtained for fibromyalgia corresponded the most – an increased opioid consumption of 9.1mg for every 1-point increase on the 0 – 31 point scale.

What does this mean for nonmedical clinicians working with people in that important post-operative period?

Along with factors we already know about, such as the tendency to catastrophise or “think the worst”, it means this group of people need extra special care. Maybe we need to be very certain that these people have good pain relief on board before we start getting them to move. Maybe we need to carefully grade the amount of movement we ask from them in those early hours and days. Maybe we need to follow them up with very precise and careful prescribed exercises, and review these “at risk” people earlier than we need to for others.

Pre-operatively too, we might have some good things to suggest.

Watching our language – being cautious about emotive or alarmist language. Giving people visualisation and mindfulness training so they can use all that wonderful descending inhibition to reduce the sensitivity of their nervous system. Good relaxation, mindfulness, visualisation and diaphragmatic breathing is something people need to learn and be confident with well in advance of needing it. Letting people know that surgeons put the knee through its paces while they’re anaesthetised, so they know that the range of movement limitation they feel is due to post-operative healing rather than the joint not being properly seated in the joint. Giving people a guideline of the expectations we have for them to be able to get up and about despite pain – and that if they need pain relief, we will ensure they have it, irrespective of whether they seem to need “more” than we would expect.

Most importantly, I think allied health need to assess for the increased risk for having a sensitive nervous system before surgery, so we can take far greater care to reassure them and help them settle their nervous system down themselves.

Brummett CM, Janda AM, Schueller CM, Tsodikov A, Morris M, Williams DA, & Clauw DJ (2013). Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study. Anesthesiology, 119 (6), 1434-43 PMID: 24343289

This is from NOIJam – a great example of how it might work

AN ACERBIC OPINION VERSUS A SWEET SOLUTION TOWARDS CHRONIC PAIN

In honour of open dialogue amongst people interested in chronic pain management, I am publishing Dr John Lyftogt’s response to the original post I published by Dr John Quintner “Sugar coated nerves”.

I want to make it clear that when guest authors are permitted to publish material on Healthskills, this is done to open dialogue and for calm and reasoned discussion. People with chronic pain, and those clinicians who provide interventions of any kind to alleviate the problems of chronic pain, have not yet arrived at any kind of “cure” or “fix” for the problem. We need to learn from one another – then we need to carry out good, systematic and scientific research to evaluate both the outcomes (eliminating as much bias as possible), and hypothesise about the mechanisms involved. I think we have a very long way to go.

REPLY TO SUGAR COATED NERVES (originally contributed by Doctor John Quintner) by Dr John Lyftogt.

The ‘latest fad in pseudo-science’ or does Glucose/Dextrose have an analgesic effect?

For millennia Jewish male neonates have had circumcision under oral Glucose/Dextrose anaesthesia. Many neonatal painful procedures are commonly conducted under Glucose anaesthesia and a systematic review of 14 RCTs confirms the effectiveness of Glucose as an analgesic agent. (Harrison).

Unfortunately no scientist to date has investigated this common phenomenon. Not even Professor Douglas Zochodne, although he has published a study on subcutaneous near nerve injections with low dose morphine.

It would be easy to repeat the same study with Glucose in sterile water as a control.

There are probably two reasons why scientists are not interested in this curious effect of Glucose:

1. funding could be difficult without Big Pharma support 
2. finding a solution to chronic pain is not conducive to an academic career.

For over 50 years Diabetes scientists have known about Glucosensing neurones: “Glucosensing neurons are specialized neurons that use glucose as a signalling molecule to alter their action potential frequency in response to variations in ambient glucose levels” (Barry). Glucose is increasingly viewed by scientists as a molecule with two separate functions. A metabolic and an inter-neuronal signalling function (Gonzales). Glucose sensing neurones have already been identified in the Hypothalamus, Vena Cava and Enteric system. They are probably small peptidergic C-fibers.

Meaningful chance observations in clinical practice have a long history of opposition from funding and regulating bodies in Medicine. E.g. Semmelweis washing of hands in labour ward in the 1830s reduced maternal death by 90%, but lead to his dismissal, eventual committal to an Asylum and death from a clobbered skull. More recently Barry Marshall’s observation in 1982 that Peptic Ulcers were caused by a bacterium (HP) led to his dismissal from the Royal Perth Hospital. He was awarded the Nobel Prize for Medicine in 2005 however.

All this happened in Dr Quintner’s home town. He should be well familiar with mainstream medicine’s kneejerk denial of innovation as has been happening with ‘Glucose analgesia’ over the last fifty years.

Dr George Hackett was the founder and prolific author on Prolotherapy in the 1940-1960s. He published his 19th paper on Prolotherapy for Headaches in 1962. (Hackett) He reports on eighty-two consecutive patients with occipito-cervical disability treated with prolotherapy over a four year period. Good to excellent results were reported by 90%, with lasting success. In the article’s introduction he comments that “Recent scientific interpretation of the devastating effects of excessive antidromic impulses and their clinical application are described”. Here is the first description of an effective treatment with hypertonic Glucose for conditions now known as neuropathic pain due to neurogenic inflammation.

Despite more than 50 years of continued success with prolotherapy and an increasing number of RCT’s confirming this, scientists refuse to have even a modicum of curiosity into the analgesic and trophic effects of glucose. Mainstream medicine with its emphasis on Central Nervous System sensitisation and pain management can only offer relief to at most 30% of those who suffer chronic unendurable pain. This dismal track record in relieving pain and suffering should be a potent stimulus for investigation, and here I quote Hackett in his 1962 paper on headaches, “for scrutinizing every fact, theory or idea that might enlighten us to the pathology, pathophysiology and treatment of these patients”.

Neural prolotherapy (NPT) is the application of isotonic Glucose/Dextrose to sensitised peripheral nerve trunks by way of subcutaneous near nerve micro-injections. It results in an immediate, profound and quantifiable reduction of mechanical allodynia. Repeat treatments reverse the underlying neurogenic inflammation causing neuropathic pain and lead to restoration of tissue homeostasis. Treatment with NPT allows for normal physiological repair of the nerve trunk and surrounding tissues. This has been documented in tens of thousands of patients and large numbers of Ultra Sound examinations before and after treatment. The treatment is now available worldwide in twelve different countries by Doctors who have been trained in Neural Prolotherapy.

Ongoing ridicule of Neural Prolotherapy by specialists like Dr Quintner, who has never witnessed a Neural Prolotherapy treatment or discussed the outcomes with patients whose lives have been transformed by NPT, is gratuitously offensive. Cynical put downs of ‘anecdotal evidence’ does nothing to enhance the reputation of mainstream medicine as it merely results in diminishing the validity of patients experiences in their battle with unendurable pain. Several RCTs on NPT will be published this year in reputable journals all confirming the above. More than fifty years of denial of the analgesic effect of Glucose/Dextrose by scientists is further evidence that they do not have the slightest interest in the care of chronic pain patients. NPT is an effective, safe and economical treatment for chronic pain and mainstream medicine exponents like Dr Quintner merely require an open mind.

Harrison D. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child 2010; 95:406-413 CONCLUSION: Glucose sublingual is and effective analgesic in infants between 1 and 12 months of age
Barry E. Levin,1,2 Vanessa H. Routh,3 Ling Kang,2 Nicole M. Sanders,4 and Ambrose A. Dunn-Meynell1,2. Neuronal Glucosensing. What Do We Know After 50 Years? DIABETES, VOL. 53, OCTOBER 2004
Min-tsai Liu1, 2, Susumu Seino3, and Annette L. Kirchgessner1, 2 Identification and Characterization of Glucoresponsive Neurons in the Enteric Nervous System. The Journal of Neuroscience, December 1, 1999, 19(23):10305-10317
J. Antonio Gonzàlez1, Frank Reimann2 and Denis Burdakov1.Dissociation between sensing and metabolism of glucose in sugar sensing neurones. Department of Pharmacology, University of Cambridge, Cambridge CB2 1PD, UK.
Hackett G S, Raftery A, Prolotherapy for Headache. Pain in the Head and Neck, and Neuritis. HEADACHE, April 62

Teams, roles, and contributions

I’m quite keen to generate some more discussion about how individual professions can contribute within Interdisciplinary/Interprofessional Team without being defensive of their contribution, nor allowing other disciplines to encroach on their specialist skills.
I really struggle with the whole concept of “role definition” because so often I see “the OT role is…” without considering that there are a number of core areas many health professionals in pain management use such as goal setting, relaxation, pain “education”, activity pacing/management, relaxation, biofeedback, cognitive behavioural therapy.

Some examples: Once I heard an occupational therapist say that only occupational therapists should “set functional goals”. Yet if goal-setting is client-centred, I can see how physiotherapists, nurses, social workers, psychologists and doctors can ALL work with a person to “set functional goals”.

I also heard an occupational therapist suggest that “only” occupational therapists should go into the home, or workplace. Yet I’ve had some fabulous physiotherapists and psychologists go into both these places and do fantastic work.

The current debate is whether occupational therapists or physiotherapists should do mirror therapy or laterality training.

Sadly I also heard of a doctor who told the interdisciplinary team that he thought it was fine to advise a person to begin a walking programme – without consulting a physiotherapist! Oh no! How dare he! Actually, isn’t this what many nonmedical clinicians have been wanting our doctors to do? And if a physiotherapist begins talking about function in the real world, isn’t this what occupational therapists have been saying physiotherapy doesn’t do but should? Seems to me we don’t recognise our own cognitive dissonance even when it’s sitting right in front of us.

To be quite honest – I don’t care WHO does what! As long as a clinician is competent, the client has had a hand in establishing priorities, and there aren’t two clinicians doing exactly the same work, to me it does not matter.
BUT I’d love to find out some other points of view, and poke holes in my assumptions – so, go to it ladies and gentlemen!

Someone asked me “so what are the skills people should have to work in chronic pain management?”

1. I’m thinking about this right now – firstly, people who “get” pain. So well-educated, knowledgeable people who have a really good grasp on neurobiology and psychology of pain. I don’t really care about the professional background, but I’d like someone who can reassure patients/clients that their pain (a) has a name (b) doesn’t mean its harmful (c) can be managed. I would help if one person in the team can prescribe rationally.
2. Someone should address movement and pain - don’t care if it’s an occupational therapist, physiotherapist, exercise physiologist or whatever. Best if this person can grade movement from simple/low intensity to higher and definitely functional intensity. And critically, that person needs to know the relevance of any exercise on what the client/patient does in daily life.
3. Someone else needs to talk about the meaning of pain on the sense of self, and help the person understand that doing things differently doesn’t mean losing your self concept.
4. It would be good to have someone who understands behaviour, and interactions between behaviour, emotions and cognitions.
5. Absolutely, someone in the team needs to help the person identify what they WANT to, or NEED to do to feel complete, then help the person work out ways to do that.
6. And I think it’s vital someone can interpret psychometrics, and knows enough about outcome measurement to produce regular reports on how participants in pain management are doing once they leave the service.

And all the other things like using biofeedback, diet, relaxation, communication, health literacy, would need to be incorporated by those will skills in these areas.

I think teams need someone who will bat for them in management, someone who really cares about the team and how it functions, and will wave the flag in terms of retaining an interdisciplinary self management focus, ensuring the team remains client-focused and team-focused, rather than discipline-focused.

Teams need to negotiate their contributions (note I say contributions not “roles” – contributions are offered, roles are defined and possessive). Team members need to renegotiate what they can offer when new team members join the team, or when a team member develops a new skill. Defining one “role” means, implicitly, that other roles are also “defined”. Sometimes this happens without negotiation. And if role definitions are not regularly reviewed, innovation and responsiveness drops, positions get reified – and we end up with a cookbook approach to pain management that means the personal relationship between the person who has pain and his or her clinicians is valued less highly than the professional title of the clinician. I don’t see this as client-centredness.

One argument for defining roles is to avoid duplicating skills. It’s intended to ensure “the right clinician with the right skills sees the right patient at the right time”. I think this ignores the common skills all clinicians working in chronic pain management need. It ignores individual team member development. It means clinicians who are not “meant” to do the tasks nominated within another role’s definition can’t develop their skills to support one another within the team. It creates barriers and obstacles to developing a common language, using a common model (cognitive behavioural approach, in the case of chronic pain management), developing common goals. It can lead to multidisciplinary practice instead of interdisciplinary/interprofessional teamwork.

It can, unintentionally, create over-servicing because instead of selecting clinicians to work together on the basis of what the client/patient needs, professional demarcation lines are drawn and THREE clinicians need to work with the client/patient instead of two. Maybe even more because if the person needs to develop communication skills at work – maybe the occupational therapist “should” work on this; if the person needs to develop effective communication at home – maybe the social worker “should” be involved; maybe it “should” be the psychologist because it’s about the person’s core schema. See how complex this can become? It’s even more difficult if we look at activity management. Should the occupational therapist be involved because it’s about occupation? Or the psychologist because it’s about contingencies and core schema? Or the physiotherapist because it’s about building exercise tolerance? Or the social worker because it’s about negotiating boundaries with other people?

Teamwork – more than a group of clinicians who happen to work with the same patient.

 
Sandra G Leggat (2007). Effective healthcare teams require effective team members:
defining teamwork competencies BMC Health Services Research, 7 (17), 1-10 : 10.1186/1472-6963-7-17

Interdisciplinary? Or serial monotherapy?

Teamwork can be a mixed blessing. Knowing that other members of the team are working alongside you is wonderful but a team that’s not functioning well can be a destructive animal that can tear itself apart.

I’ll begin with some definitions:

Monotherapy means having a single type of intervention. This is useful for acute problems, or very simple problems. For example, if I sprain my ankle, I might need to see a physiotherapist to improve my mobility. In New Zealand, the ACC-funded Psychological Pain Management sessions are a good example.

Multidisciplinary means more than one discipline working with an individual, but not necessarily working with one another. This is useful where coordination is difficult, such as in a busy Emergency Department, or where the problem doesn’t need collaboration, for example possible neuropathic pain post-deQuervains release where the patient needs physiotherapy, medication and help to return to work. In New Zealand, a good number of the ACC-funded Activity Focused Programmes run this way.

There may be a physiotherapist, occupational therapist and psychologist working with the same patient, and although they may share notes their interventions remain focused on their individual disciplinary contributions. The way the disciplines conceptualise the patient’s problems remains within the individual professional’s model. So the physiotherapist might focus on biomechanics and strength, the occupational therapist may consider how the individual manages his or her driving and work tasks, while the psychologist may consider the person’s thoughts and beliefs about pain. Although the disciplines acknowledge one another’s contribution, clinicians focus on their own intervention and clinical reasoning with little reference in their own sessions to anything another clinician has looked at.

Interdisciplinary means professionals from a variety of disciplines working together in an integrated way with joint goals and ongoing communication. A common model is used, joint goals developed, clinicians contribute in the area/s most needed by the patient/client, share session content and communicate regularly so other team members can provide the same message in their sessions. This might mean the physiotherapist uses cognitive reframing during exercises, the occupational therapist discusses medications and side-effects during activity planning sessions, the psychologist talks about exercise timing and intensity during a session using biofeedback.

The popularity of interdisciplinary pain management has waned somewhat since the days of the mid-1980′s to late 1990′s. Health administrators look askance at large teams because they seem expensive, time is tied up in meetings, there are turf wars, people talk about role conflict and role confusion, time is needed for induction, and there’s always a suspicion that having a team leads to over-servicing and too many cooks spoiling the broth. I’ve watched the integrated interdisciplinary approach gradually being replaced by a multidisciplinary approach, although the language may not have caught up with this!

Teams are a complex beast. To understand teams we need to draw on cognitive psychology, social psychology, rehabilitation research, general systems theory and, dare I say it, management theory.  Not only do clinicians in an interdisciplinary team need to know their profession’s contributions, they must also communicate effectively as individuals, have learned how to collaborate, and the team must be supported in a structural way to do its job well.

What does this mean in practical terms?

There must be effective selection and induction process for new team members – members need to be chosen for teams on the basis not only of their proficiency in their individual discipline, but also on what they can contribute individually to a team. Personally I don’t think a decision to appoint an individual to a team should occur without the team being involved in the selection process.  Induction needs to involve not only where the first aid kit is, but more importantly, the team’s philosophy and clinical model, sharing what each individual member can contribute to the team – especially when a new member is appointed, how decisions are made, how disputes are resolved, and the team’s values.

Time must be set aside for team development and that hackneyed term “team building”. This is an ongoing need – because trusting one another is critical to effective teamwork. This means learning about other clinician’s contributions – enough to be able to provide the same kind of input within your own clinical session, so a consistent message reaches the patient.

Communication must be pretty robust at times! What I mean by this is that it’s vital to be able to disagree, challenge one another’s viewpoint and take the time to reach alignment, if not agreement. A team that can’t or won’t openly disagree with one another is likely to hold onto disputes, souring the relationships and creating distrust. Over time, the team’s effectiveness is lost as patients/clients can tell where the weakest links lie.

Develop a structure for presenting information

–Optimum amount of information – 3-7 from each person

–Most likely to be forgotten – presented first

–Lowest prestige – presented early

–Share unique information rather than shared

–Use a timer to limit discussion – egg timer?

–Consider using delphi, or other structured decision process (nominal group technique, SWOT, decisional balance, cognitive mapping)

Identify functional roles as well as clinical roles in a team, support these roles – this means some people are the “organisers” in the team, some are the “comforters”, some are “rule makers”, some are “enforcers”. These interpersonal roles are as important as clinical roles because they facilitate team functioning. And the professions traditionally expected to “lead” or “organise” may not be the best individuals to do so in a particular team.

Develop a process for resolving differences - this might mean sitting and thrashing a problem out in discussion, or it might mean bringing another person in to mediate/arbitrate, or it could mean giving a decision-making role to one individual within the team, though this can mean developing a hierarchy and this is less positive within an interdisciplinary team.

Managers must recognise that interdisciplinary teams need time to learn to work together, that teams are less effective when team membership changes, that members of teams often know what they need and who they need as members and that external managers or even clinicians working outside a team may have little knowledge either of how the team works, or of what the team needs to be effective.

Are interdisciplinary teams effective?

This is a slightly difficult question to answer, but overall the indications are that interdisciplinary teams are effective in terms of patient outcomes, and they are also better for the individuals involved in them. This report, somewhat old now but still relevant, found that IDTs are better for mental health of members and there is lower staff turnover.  This report, from 2013, finds that the data are not yet clear about cost effectiveness.

What seems evident is that the more complex a patient’s problems, and the more chronic, the greater the need for interdisciplinary teams, and the more cost effective the outcomes.

For more information on interdisciplinary teams – the District of Columbia Area Health Education Center has an excellent module on IDT

Open access to the Canadian Pharmacists Review article on interdisciplinary teams

Canadian’s can be proud, here’s another document, this time from EICP

Human Resources for Health provides this summary - 10 Principles of Good Interdisciplinary Team Work

I love working in a team. I love being able to trust the other members of the team to provide seamless integration of the things I contribute, and I love being able to support the other clinicians in their approach. I know it’s not easy to develop good teamwork, but there’s enough information available from research to know what can help. What I definitely know is that defining what one profession will do without also considering both the other professional’s contribution AND the personal strengths and vulnerabilities of the individuals involved is likely to lead to subversive behaviour, dissention and ultimately failure for the person at the centre of it: the client/patient.

Research opportunity!

If you are a clinician who works with people who have pain, I am conducting a survey of health professionals’ beliefs about spirituality and pain.

This project aims to explore the beliefs about spirituality of healthcare professionals involved in the care of people who are experiencing pain.

Spirituality has been identified as both an important aspect of healthcare and a way that individuals cope with the challenges of pain, but despite this, spiritual care is not well understood in the New Zealand pain management context.

We are seeking people who are healthcare providers involved in the care of people who are experiencing pain, and who are willing to provide us with their views on spirituality.

Thank you for showing an interest in this project. Please read this information sheet carefully before deciding whether or not to take part. If you do decide to take part, we thank you. If you decide not to take part there will be no disadvantage to you, and we thank you for taking the time to consider our request.

If you agree to take part in this project, you will be asked to complete a brief, confidential online questionnaire survey. This should take no longer than 15 minutes to complete.
If you decide not to take part in the project, there will be no disadvantage to you.

No information that could identify you personally will be kept, and all information obtained will be reported as grouped data, with the exception of some quotations from open-ended questions.
Only the researchers will have access to this information, and data will only be used for the purposes of this research project. All information will be held in secure, password-protected data files, and retained for five years.

Any personal information you provide, such as contact details will be destroyed at the completion of this research project.

You may withdraw from participating in this project at any time and without any disadvantage to yourself by contacting the researchers below.

The results of this project may be published and will be available in the University of Otago Library (Dunedin, New Zealand) but every attempt will be made to preserve your anonymity.

If you have any questions about this project, either now or in the future, please feel free to contact either:
Bronwyn Lennox Thompson
Dept. Orthopaedic & Musculoskeletal Medicine
University of Otago, Christchurch
Ph 64 3 364 1086
email: bronwyn.thompson@otago.ac.nz
or
Alison Middlemiss
Pain Management Centre
Burwood Hospital
Canterbury District Health Board
Christchurch
Ph 64 3 383 6831
email: alison.middlemiss@cdhb.govt.nz

This study has been approved by the Department of Orthopaedic Surgery & Musculoskeletal Medicine, University of Otago, Christchurch. If you have any concerns about the ethical conduct of the research you may contact the University of Otago Human Ethics Committee through the Human Ethics Committee Administrator (Ph 64 3 479 8256). Any issues you raise will be treated in confidence and investigated and you will be informed of the outcome.

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

The unmentionable pain down there

Chronic pain isn’t a popular topic in health, or even socially. Chronic pain “down there” (yes, I’m talking genitals and in both women AND men) must be the least popular topic in pain management.

I think it might be a throwback to the Victorian past, or maybe that pelvic pain isn’t usually a compensable pain so it doesn’t get blamed for work loss, but whatever, it’s just not featured all that often in pain management.

Courtesy of my wonderful friend Sandy Hilton from Entropy Physio Therapy I’ve been prodded into looking at this problem, and came across a preprint of the British Pain Society’s pelvic pain patient pathway in the British Journal of Anaesthesia.

Pathways, like any algorithm or guideline, are intended to simplify and encourage consistent approaches to a clinical problem. They are often developed by groups of specialists in the field, and in the case of chronic pain, these specialists often come from a range of disciplines. What guidelines or pathways cannot do is provide a “one-size-fits-all” solution – and they don’t pretend to. What they do offer is a consensus position in what should generally work well for people with that clinical problem. Clinicians: you still need to use your clinical reasoning, and most importantly, you still need to listen to the person who has the pain to see if any recommendations work for them.

What do these guidelines come up with?

The first and most important point made in this paper is this: “It is because of a lack of understanding of basic facts that treatment is often inappropriate.”

Oh so incredibly true – pelvic pain is often treated as if it’s a biomedical problem only, managed as if it is an acute pain problem, and people with pelvic pain are often passed from specialist to specialist – meantime the person who is experiencing that unmentionable pain down there is dealing with the ramifications of pain affecting the very intimate parts of their body. Pelvic pain affects bodily functions like urination, defaecation, sexual intimacy – things that we generally think about as private, and don’t want to talk about.

To deal with the lack of basic facts about pain and treatment, the BPS includes a great deal of supporting information within the Map of Medicine care pathway. I’m sorry that this information isn’t available to the general public, instead it’s hidden behind the proprietary Map of Medicine paywall.

Back to the guidelines:

Classifying pelvic pain appropriately (ie diagnosing it), is the first step – chronic pelvic pain is not a homogenous problem.  Some pelvic pain is an indication for rapid referral to specialist or emergency services, but what is highlighted in this document is that so many people have their pelvic pain mistakenly treated as an acute problem and (like people with chronic back pain) get an awful lot of inappropriate and invasive investigations. Now this probably doesn’t bother a more mature person – but in an eleven year old girl is tragic.

The second step is to recognise that people with pelvic pain experience psychological distress and negative behavioural and sexual problems.  People with chronic pelvic pain may have trouble with anxiety, depression, poor sleep, difficulty working, and probably most distressing of all, relationship problems. People can become very fearful – hardly conducive to good sex! The guidelines make the point that clinicians need to ask about these problems and not wait for the person to raise them.

Thirdly, clinicians need to take time to give the person information about pelvic pain at a pace they can cope with, at an informational level they can handle, and be very careful about the language they use. I don’t think it’s great to suggest “you’ll never be the same again” or “you need to be careful” or even “you’ll have this forever”. I say this last one cautiously, because I think people do need to know pain is likely to remain – BUT IT DOESN’T NEED TO BE A LIFE SENTENCE!

Fourthly, physiotherapy, while not having a great deal of evidence specific to pelvic pain, is strongly recommended in this guideline. The main approach is reassurance, and maintaining general activity level. Early and comprehensive assessment by a specialist pelvic physiotherapist (yes, an internal assessment IS necessary) is especially needed. Good physiotherapists can provide manual therapy, but will always work with the person who has the pain to learn how to do stretches and strengthening exercises, as well as desensitising activities that go a long way towards reducing the threat value of pain.

Opioids are not given wholehearted endorsement. This is great to see – there is mixed evidence for opioid use in chronic pain because it hasn’t been shown to lead to increased function, and even less evidence is available for pelvic pain. Not only that, but opioids constipate (not terrific if you have pelvic pain), can impact on the endocrine system including lowered sex hormones, and can be associated with opioid-induced hyperalgesia or an increased sensitivity to pain.

Referring for specialist help – this set of guidelines suggests primary management for a maximum of six months, and if there is not improvement referral should be made to secondary care no later than this. Of course, that’s hoping there is secondary care for chronic pain available!

When someone gets referred to secondary care, then what? Interventional therapy can be offered but the guidelines say this (and my experience supports it):

“nerve blocks rarely provide long-term benefit on their own, and consideration should be given to multidisciplinary team involvement to maximize outcomes. The pathway goes on to discuss the frequency of repeat injections, indicating that the duration of benefit and potential complications (e.g. repeat steroid use and the cumulative dangers of X-rays) need to be considered. Currently, for some injections the procedure can be performed only with Computer Tomography (CT) guidance, even with modern scanners a significant radiation dose to the pelvis is required. In a secondary care setting, interventions need to be supported by physiotherapy, graded activity, explanation, education, and self-management (Baranowski, Lee, Price & Hughes, 2014, p. 4).”

I’m not sure why these other modalities aren’t required in primary care, because they probably empower the person far more than being injected. I think it relates to the poor funding to support allied health working in primary care – at least, that would certainly be the case in New Zealand.

I’m sad that although there are some great recommendations in this guideline, I’d like to see it go further. Maybe it’s the rebel in me, maybe it’s because it’s difficult to get seen in a secondary care setting, and maybe it reflects the limited evidence base for treating pelvic pain, but I’d like to see the conservative physiotherapy, graded activity, explanation, education and self-management promoted up-front and from the beginning.

Why wait? Waiting leads to more distress, more relationship disruption and more cost.

I haven’t seen anything like this guideline available in New Zealand – would that it were, because I find it distressing that young girls go through multiple invasive procedures that inevitably lead to tissue damage and post-surgical pain, and increase the risk of chronic pain (surgery is a risk factor for chronic pain). I know the clinicians intend to do the right thing, but I wonder if allied health clinicians were more widely funded to work within private healthcare in New Zealand, the need to do surgery might be reduced. Of course we might need to do some research – and some lobbying. What do you think?

A. P. Baranowski1, J. Lee, C. Price and J. Hughes (2014). Pelvic pain: a pathway for care developed for both men and women by the British Pain Society British Journal of Anaesthesia DOI: 10.1093/bja/aet421

Kalso, E. (2013). IV. Persistent post-surgery pain: research agenda for mechanisms, prevention, and treatment. British Journal of Anaesthesia, 111(1), 9-12. doi: 10.1093/bja/aet211

 

Coping: neither good, nor bad, but “it depends”

Coping is a concept we often use in chronic pain management.

Our aim as clinicians is to help people with chronic pain cope with their pain so they can do more of what is important to them.

Most of us know that coping mediates between the individual and whatever challenge he or she is facing. Coping reduces the impact of the challenge. Most of us also know that there are a range of coping strategies that people can use – and most of us have learned that coping strategies can be “adaptive” or “maladaptive”, “active” or “passive”, “approach” or “avoidant”. Unfortunately, much of the time this dichotomous taxonomy turns into a “do this” and “don’t do that” list of good or bad strategies.

What this means is that strategies such as resting and delegating are both considered “passive”, therefore “avoidant” and consequently are “maladaptive” – and as clinicians we tell people “don’t do that” because they feature on our list of bad strategies.

I thought this too until I started researching the ways that people who cope well with pain deal with pain in their lives.

I thought, when I began my study, that I would find a neat list of strategies that people used, and that these would fall into the “adaptive”, “active” and “approach” categories of coping.

They don’t. Nope, people who live well with their chronic pain just do not do what I expected.

People who cope well use “anything and everything”, or as my participants put it “anything that works”.

Back to the drawing board you’d think! But I spent a long time listening to the ways people solve the problem of how to get on with life despite chronic pain, and something struck me: when a person talked about using a coping strategy, any coping strategy, it wasn’t all about the pain. In fact, pain rarely got a mention.  What did get discussed was how, by using “anything that works”, people got to do what they valued in their lives. In other words, they judged whether a strategy worked by how well it helped them do what they prioritised.

In technical terms this is called functional contextualism – evaluating an action in the context in which it is used. Coping strategies cannot, within this framework, be evaluated in isolation from the where and why of its use.

Let me give you a brief example: Resting is usually thought of as an unhelpful way to manage chronic pain. It’s thought to lead to deconditioning, avoidance and fear of pain, and loss of good things in life. Yet, what if, by resting in the afternoon, a person is able to go out to celebrate her 21st birthday? In the context of a person having a 21st birthday party, resting in the afternoon enables her to do something she values.

If resting is the only coping strategy this person has, or if resting is the primary way this person copes with painful flare-ups, and if resting also interferes with this person’s overall ability to live independently, then perhaps resting is not useful for her all the time. On the other hand, if she has many different ways to deal with her pain, and she also uses planning and medication and exercise, and if she’s able to live independently and do the things she wants to be able to do, resting has usefulness.

That’s functional contextualism, and that’s how people who cope well with pain use their coping strategies.

What does this mean for us as clinicians?

It means we need to take time to understand why, when, where and how the people we work with do the things that are important to them. If they don’t know how to do what’s important, if they only have a few coping strategies to choose from, and if they’re distressed because their one strategy gets in the way of things they value, then and only then are their coping strategies unhelpful. It also means that using a coping strategies inventory might not be a good way to decide if a person needs help developing coping strategies. We might instead choose to use something like the Chronic Pain Coping Inventory as a way to identify the range of strategies an individual knows about, rather than whether the things they use are “passive” or “active”. To measure whether their strategies are working for them – well my guess would be to use something like the Canadian Occupational Performance Measure, or a disability outcome measure.

Biglan, Anthony, & Hayes, Steven C (1996). Should the behavioral sciences become more pragmatic? The case for functional contextualism in research on human behavior Applied & Preventive Psychology, 5 (1), 47-57 DOI: 10.1016/S0962-1849(96)80026-6

Hayes, Steven C., Levin, Michael E., Plumb-Vilardaga, Jennifer, Villatte, Jennifer L., & Pistorello, Jacqueline. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180-198.

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.

More discussion on Functional Capacity Evaluations

Some years ago I wrote about Functional Capacity Evaluations and the lack of evidence supporting their use, particularly their use as predictive tools for establishing work “fitness”. 

I’ve received some sharp criticism in the past for my stance on FCE, and I continue to look for evidence that FCE are valid and reliable.  I haven’t found anything recently, and I’m still concerned that FCE are used inappropriately for people with chronic pain.  There is nothing like the demand characteristics of a testing situation for a person with chronic pain to either push themselves – and have a flare-up for some days afterwards but get a “good” report suggesting they have put in “full effort” and that they can manage a full time job of a certain MET demand; or to pace themselves, using pain management strategies – and avoid a flare-up but receive a “bad” report, suggesting they haven’t put in “full effort” and despite this, they can manage a full time job of a certain MET demand.

I can’t understand why FCE providers don’t work alongside people with chronic pain and their vocational counsellors, to help them define their sustainable level of physical demand, and systematically help them to gain confidence that they can find suitable work without exacerbating their pain. 

For the record, I’m not against establishing functional abilities.  And I think having a systematic approach to doing this.  I am against FCE’s being touted as a way to reliably determine work capacity, or to being able to determine “effort” through “consistency”. There simply isn’t published evidence to support these claims.  If someone can provide me with evidence, I’ll gladly change my mind because if there is one thing scientific training teaches, it’s that it’s OK to change your mind – if there’s evidence to do so.

This doesn’t mean that FCE’s would then be fine and dandy – because, as I’ve seen far too many times – HOW they’re used goes often well beyond what any FCE can possibly do, and very often is used as a blunt instrument when some good motivational interviewing and careful vocational counselling would achieve the same.

Here’s my original post, and some very good references are at the end of it.