Pain Management

1
Pain Management Acupuncture

• Simon Strauss MBBS Monash 1972.
• Dip. Acupuncture Nanking 1978
• This session
• Historical Perspective on Acupuncture
• Pain Epidemiology - The Market
• Introduction to Myofascial Pain Theory
• The Near and Far Acupuncture Technique

2
Acupuncture Practice - An Established Trend

• Growth of Acupuncture Outlets - Brisbane

3
Acupuncture Item 173 (980)

• From 1984 to 1995 (National)

4
Attitudes are age related.
5
NHMRC. W.P.Document Management of Severe Pain

• Core Curriculum for Medical Practitioners -
  Identifies a need for Education on
• Acupuncture and Transcutaneous Nerve
• Stimulation techniques.
• The measurement, quantification and
• recording of pain.

6
International Association for the Study of Pain
(IASP)

• Management of chronic pain Core Curriculum for
  Medical Practitioners, Dentists and
  Physiotherapists - Recommends Education on
• 1.Neurostimulation techniques including
• a. Transcutaneous nerve
  stimulation
• b. Acupuncture
• 2. The measurement, quantification and
• recording of pain
• 3. Myofascial Pain

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What are the Dominant Factors Driving this
Acceptance of what only a Decade ago was regarded
as Alternative or Fringe?

• It Works
• The results depend on the practitioners
  skill.(Operator satisfaction)
• Its mechanisms can be understood from a Western
  scientific viewpoint
• It is cost effective for the consumer
• It has a high efficiency index.( ve effects far
  outweigh side effects.)

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ADDITIONALLY

• There is considerable demand
• 1. As Western Countries are experiencing an
  Epidemic of Chronic Pain.
• 2. That is poorly managed with our classical
  techniques!

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The Epidemiology of Pain An Australian Study

• Brisbane. by F. Guthrie, F. Nicolosi
• and S. L. Strauss.
• Telephone survey of 265 Households
• Household pain prevalence rate, 35.5
• Adult Individual pain prevalence, 19
• Overseas studies, (Canada, USA) have shown
  similar prevalence rates.

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Pain Prevalence Increases with Age.

• 10 of 30 year olds
• 25 of 50 year olds
• 45 of gt60 year olds
• Over the age of 30 females pain incidence is
  higher than that of males.
• The Epidemiology Pain An Australian Study

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Location of most severe pain The Epidemiology
Pain An Australian Study

• As of Pain States declared

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Intensity The Epidemiology Pain An Australian
Study 45 can be regarded as suffering from
severe pain

• 
  

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Duration The Epidemiology Pain An Australian
Study 91 have Chronic Pain

• Time since first occurrence of Pain State

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Frequency The Epidemiology Pain An Australian
Study53 Daily or constant

• Frequency of Pain Occurrence as a

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Cause of Pain state

• Post Surgical 2.6
• Sports Injury 3.4
• Accident 18.8
• Other 19.7
• Work Related 21.4
• Spontaneous 34
• The Epidemiology Pain An Australian Study

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Health Professional Consulted.

• 70 visited a Health Professional
• 30 no treatment or self treatment
• The Epidemiology Pain An Australian Study

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Of those visiting a Health Professional

• 80 consulted a Medical Practitioner
• 8 consulted a Chiropractor
• 5 consulted a Physiotherapist
• 2 an Acupuncturist (Non-medical)
• The remaining 5 - Naturopath, Herbalist,
  Iridologist etc.
• The Epidemiology Pain An Australian Study

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The Epidemiology Pain An Australian Study
Summary

• Household pain prevalence rate 35.5
• Adult Individual pain prevalence 19
• 91 chronic pain (gt 6 months)
• 45 severe to unendurable Pain Intensity
• 53 constant or daily
• Back 33, head and neck 24, leg 22
• 70 managed. (80 of managed -Medical)

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10 High StreetA Private Practice
Multidisciplinary Pain Clinic.

• Core Group S Strauss, T McCarthy.
• Physiotherapist, Psychiatrist, Masseuse
• Established 1980
• Research oriented
• 10,000 Patients.(25 new patients per week.)
• 60 Referred.

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10 High Street. Pain State Distribution Age

• Breakdown of 1146 Patients Pain Syndromes
  
  

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10 High Street. Pain Severity97 Could be
regarded as having severe pain

• No Pain
  Unbearable Pain
• 
  

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10 High Street Compared c General Pain Population

• Comparison of pain severity

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10 High Street. Reason for Presentation

• Other forms of treatment had not helped 63
• Id have tried anything if I thought it would
  help 61

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10 High Street Patients Profiles.

• A picture emerges of desperate patients
  suffering severe to unendurable pain for several
  years, who had tried multiple forms of therapy
  without gaining sustained relief.
• The majority of these patients syndromes
  involved the musculoskeletal system.
• 10 High Street patients had more severe, more
  prolonged Pain States than those identified as
  having pain in the general community.
  
• ? Due to referral bias. ( ? Fear of needles)

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10 High Street. Research Areas of Interest

• Initial Aim was to explore Acupuncture's place
  within Western Medical Practice Its Mechanisms
  and treatment results.
• Led to an in depth investigation into
• Trigger Points
• Sympathetic Involvement
• Pain Measurement Subjective Pain
  diagrams,
  VAS, McGill Pain
  Questionnaire
• Pain Measurement Objective
  Thermography,
  Algometry, Axon
  Flare,
• 
  Differential Nerve Blocks
• 
  Neurotrace, Cryoprobe etc
  
  

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Cold Bi Syndromes A Starting Point

• T.C.Ms Cold Bi syndromes include the majority of
  chronic pain states where Ah Shi (Oh Yes) points
  are associated with coldness of the painful area.
  Nanking School TCM.
• T.C.M. characterises this coldness as being due
  to a blockage of the flow of Qi and blood.
• The T.C.M. treatment paradigm is to, Remove the
  obstruction thus allowing warming and nourishing
  of the tissues.

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Cold Bi Syndromes A Starting Point

• In Western terms this equates to deactivating
  the Trigger Point thereby decreasing the
  local/regional, aberrantly enhanced, sympathetic
  outflow activity usually associated with active
  trigger points.

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Myofascial Trigger Points Janet Travell. 1976

• Myofascial Trigger Points are among the most
  common, yet poorly recognised and inadequately
  managed, causes of musculoskeletal pain seen in
  Western
• medical practice.

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Myofascial Trigger PointsMostly Missed

• The majority of chronic pain patients seen at 10
  High Street had active trigger points.
• Very few had had their trigger points palpated
  prior to presentation.
• Most expressed surprise when their pain syndrome
  was reproduced by palpation.

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Myofascial Trigger PointsMostly Missed, Why?

• Nearly all had never filled out a Pain Diagram,
  McGill Questionnaire, VAS etc.
• Many had not been undressed at previous
  assessments.
• Many had accepted being told that their pain had
  no physical cause.
• Contrary to prevailing paradigm.( The Tomato
  Principal)

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Recent Studies (IASPs Journal PAIN)

• Have shown that the syndrome of
• Chronic Benign Intractable Pain (previously)
  defined as pain that has been present for more
  than six months without known peripheral
  nociceptive input is nearly always associated
  with Trigger Points. ( Back 96.7, Neck 100)
  Pain. Vol.37 1989.

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Recent Studies (IASPs Journal PAIN)

• Have shown that Non Specific Low Back Pain in a
  General Practice setting is usually (80)
  associated with Trigger Points. Pain. Vol.37
  1989.
• More than 50 of patients admitted to chronic
  pain programs (USA) were found to be suffering
  from Myofascial Pain Syndromes due to trigger
  points.Textbook of Pain Ed. Melzack and Wall.

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TRIGGER POINTSThe Emerging Western Paradigm

• Trigger points are increasingly thought to be
  important in the pathogenesis of many chronic
  pain syndromes.
• They can be thought of as ( T. McCarthy 1983)
• Pain Amplifiers
• where their activity enhances nociceptor input.
  eg. Osteoarthritis,
• or augments sympathetic activity.
• eg Reflex Sympathetic Dystrophy, Post Herpetic
  Neuralgia etc.

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TRIGGER POINTSThe Emerging Western Paradigm

• Trigger points are increasingly thought to be
  important in the pathogenesis of many chronic
  pain syndromes.
• They can be thought of as ( T. McCarthy 1983)
• Pain Generators
• where the trigger point is the actual tissue
  causing the pain state.
• i.e. Myofascial Pain Syndromes.

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TRIGGER POINTSRxs Directed _at_ the Trigger
Pointin theWest

• Spray and Stretch
• Ischaemic pressure massage (Shiatsu)
• Injection ( Local Anaesthetic, etc. )
• Dry Needling (Superficial /-Xple, Deep)
• Acupuncture

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The Near and Far Acupuncture Technique

• Was historically and still is the most commonly
  used Acupuncture technique for the resolution of
  chronic pain syndromes in the Peoples Republic of
  China.
• When Acupuncture is used to treat common pain
  states the treatment is aimed at resolving the
  tissue problem or reflex causing or maintaining
  the pain state.

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The Near and Far Acupuncture Technique

• Two processes are dominant in this
  rehabilitation
• 1. The Ablation of Trigger Point activity
• 2. The Restoration of Disordered blood flow
• The provision of Analgesia in this context is a
  secondary consideration. (Electro-Acupuncture
  stimulation is rarely used in this context.)

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The Near and Far Acupuncture Technique

• Involves the use of both
• local
• and
• distal
• Acupuncture points.

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Local Points - AhShi - Oh Yes - Trigger Points

• The local points are usually
• Ah Shi (Oh Yes) Points
• Oh yes as when palpated they reproduce the
  patients pain syndrome

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Local Points - AhShi - Oh Yes - Trigger Points

• The Western equivalent of the AhShi point is
  the Trigger Point
• gt 75 of Local Acupuncture Points for Pain
  correspond to Trigger Points......
• R. Melzack

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Distal Acupuncture Points

• Are classical meridian Acupuncture points
• and are found below the elbow or knee.
• They are used for the treatment of many
• diseases.
• Distal Acupuncture Points can be used to
  manipulate
• 1. the sympathetic
  nervous system.
• 2. the various Pain
  Gates

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Distal Acupuncture Points

• In the pain Rx context
• Commonly used distal points are
  characteristically found in muscles often at the
  motor point. eg. Li 4, Hegu. Li 10,
  Shousanli.
• The correct distal point is frequently tender.
• Complex rules can govern their selection.

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The Near and Far Technique for Chronic Pain
States Nanking 1978Local Points

• A fine 30 - 32 Gauge needle is painlessly
  inserted through the skin over the active trigger
  point/points.
• The needle is then twirled (900 left-right ) with
  downwards pressure until the trigger point is
  penetrated and needle grasp Objective - Deqi
  occurs.
• At this stage the patients typical pain
  can/should be replicated. Qi reaching the pain
  -a type of Subjective Deqi or Acupuncture
  sensation

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The Near and Far Technique for Chronic Pain
States Modified for Australian conditions.
Local points.

• Western patients frequently resent feeling
  Subjective Deqi!
• A good result can also be obtained by stopping
  the needle manipulation immediately following the
  penetration of the ahshi or trigger point.
• Other techniques have also evolved, where the
  skin over the trigger point is penetrated several
  times or a heavy needle is canter levered in
  the dermis.

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The Near and Far Technique for Chronic Pain
States Nanking 1978. Distal Points

• Distal points are found below the elbow or knee
  and are used to provide analgesia and or
  sympatholysis.
• The skin over the distal points is painlessly
  penetrated
• The needle is again Twirled 90-1800 left -
  right as well as up and down until needle grasp
  or subjective Deqi is experienced.
• This distal point subjective Deqi can be
  sensations of numbness, tingling, distension or
  dull pain.
• The amount of deqi provided is titrated against
  the condition. Acute/Shih heavy, chronic/Xu
  milder.

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The Near and Far Technique for Chronic Pain
States Modified for Australian conditions.
Distal points.

• Distal points can be selected by experience /
  formula.
• The penetration of the skin over the point should
  - must be painless.
• For acute - severe pain, eg Wry neck, Stuck back,
  distal points should be needled to produce
  moderate - strong subjective deqi.
• For chronic conditions mild subjective deqi or
  even just needle grasp ( Objective deqi ) is
  sufficient.

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Correct Needling Technique

• The Acupuncturist is frequently judged by his
  ability to painlessly insert the needle through
  the skin both in China and the West and rightly
  so.

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Incorrect Needling Technique

• The consequences of poor / painful needling
  technique include
• Poor compliance ( First session is the last)
• Poor Result due to
• 1. Augmented Sympathetic
  Outflows
• 2. Not enough
  Points allowed to be
  needled / sessions attended.
• Iatrogenic / Side Effects.

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10 High Street Treatment Cascade

• Acupuncture -Near and Far technique
• Relaxation Training, including in order of
  utilisation Tapes eg Passive Muscle Relaxation,
  Biofeedback EMG / GSR, Hypnosis.
  
• Postural Re-education - Job Task
• NSAIs, Tricyclics, Finalgon, T.N.S.
• Nerve Blocks - Local Anaesthetic (Neurotrace)
• - Cryoprobe
  (Facet Joints)

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Results of Acupuncture Rxusing the Near Far
Technique.
Survey 1. 100 Referred Survey 3. NHMRC
funded Survey 4. Brisbane Medical School
( Very complex, hostile wording. ? reason
for low response rate)