10 High Street A Private Practice Pain Clinic. 1980 - 1990

1
10 High Street A Private Practice Pain Clinic.
1980 - 1990

• Core Group
• S Strauss MBBS
• Dip. Acupuncture,Nanking School Traditional
  Chinese Medicine, Nanking, China. 1978. FAMAS.
  Licentiate. AAMM
• T McCarthy. MBBS FFARACS
• Dip. Acupuncture, Nanking School TCM,
  Nanking, China. 1982. FAMAS.
• Plus Physiotherapists, Psychiatrist (Pt.1.),
  Masseuse.
• 10,000 Patients from 1980 - 1990, 60 referred.

2
10 High Street. Research Areas.

• Initial aim was to explore Acupuncture's
  place within Western Medical Practice Its
  mechanisms and treatment results.
• Led to investigation into
• Trigger Points
• Sympathetic Involvement Manipulation
• Pain Measurement
• Pain diagrams,
  VAS, McGill Pain Questionnaire etc
  Thermography, Algometry, Axon
  Flare.
• Electro-diagnosis/provocation
  (Neurotrace etc
• Nerve Trigger Point Blocks - Local
  anaesthetic, Cryoprobe etc.
• Afferent Stimulation Techniques (PSS)
• Pain Epidemiology

3
10 High Street Treatment Surveys
4
10 High Street. Pain State Distribution Age

• Breakdown of 1146 Patients Pain Syndromes.
  From survey 3.

5
10 High Street. Pain Severity

• 
  

Unbearable Pain
No Pain
97 Could be regarded as having severe pain
From Survey 4. Brisbane University School of
Medicine
6
Pain Severity 10 High Street Compared with
General Community Pain Population

No Pain
Unendurable Pain
From Survey 4. Brisbane University School of
Medicine The Prevalence of Pain
Complaints in a General Population An Australian
Study
7
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

From Survey 4. Brisbane University School of
Medicine
8
10 High Street Back Pain Patients Profiles.

• Analysis of 137 Back Pain Patients
• Pain Distribution
• 49 -Low Back Pain
• 25 -Sciatica
• 18 -Buttock Pain
• 12 -LBP Buttock
• 15 -LBP Sciatica
• 12 -Thoracic Pain
• 8 -Post-Laminectomy Pain

From Survey 2. 478 Responders. Follow up 6
months, mail survey. 75 response.
9
10 High Street 137 Back Pain Patients Profiles.

• 55 NSAIs / Analgesics (currently using on
  presentation)
• 16 Epidurals,
• 36 Chiropractic,
• 24 Physiotherapy,

8 Laminectomy/Fusion.
Total number of health professionals consulted
was 380. Average pain duration was 6.8
years. 72 c/o disturbed sleep.
From Survey 2. 478 Responders. Follow up 6
months, mail survey. 75 response. From Survey 2
10
10 High Street Back Pain Patients Profiles.

• 49 Low Back Pain Only
• 22 had their pain reproduced by pressure on
  muscle Tender Points around the thoraco-lumbar
  junction.
• ( 8 of the 22 had pelvic tilts.)
• 25 Sciatica Only
• 20 of the 25 had a Tender Point (EM- 35)
  in the Gluteal musculature, which when pressed
  on replicated all or some of their pain.

From Survey 2.
11
Analysis of 21 consecutive unilateral back pain
patients
12 females, 9 males

• Average age 57 years
• Average VAS 5 0X10cms
• Average SMPQ Sensory 5.76
• Average SMPQ Affective 1.66

From A Comparison of Axonal flares Reactions,
Pressure Algometry and Skin Temperatures to
Subjective Measures of Pain Strauss, Burns and
Sprague. Unpublished work. Brisbane Medical
School.
12
Analysis of 21 consecutive unilateral back pain
patients Temperature measurements of tender
points compared to contralateral anatomic site.
Temperature was measured with an InvotechC600M
Biotherm Infrared thermometer. Sensitivity 0.1 0C

• The mean Skin Temperature was 0.23 0C higher
  on the affected side
• Higher in 15 cases, same 2 and lower in 4
  cases. Standard error of difference 0.11, a t
  score of 2.11 giving a confidence level of gt95)

From A Comparison of Axonal Flares Reactions,
Pressure Algometry and Skin Temperatures to
Subjective Measures of Pain Strauss, Burns and
Sprague. Unpublished work. Brisbane Medical
School.
13
Analysis of 21 consecutive unilateral back pain
patients Axon Flare measurements of tender
points compared to contralateral anatomic site.

• In 20 of the 21 cases the flares, induced by
  the insertion of 30 gauge solid stainless steel
  needles into the Tender Point and the mirror
  site, were larger on the pain side.
• Mean difference of 51.4 mm2.
• Standard error of difference 0.35, t
  2.01, confidence level gt 90

From A Comparison of Axonal Flares Reactions,
Pressure Algometry and Skin Temperatures to
Subjective Measures of Pain Strauss, Burns and
Sprague. Unpublished work. Brisbane Medical
School.
14
Analysis of 21 consecutive unilateral back pain
patients The Mean Pressure Threshold

• Female Tender Points was 1.84 kg/cm2.
  (Ngt3.8)

Male Tender Points was 2.56 kg/cm2
(Ngt5.6) Threshold for whole group
Tender Points 2.4 kg/cm2.
Pressure Threshold Meter by Pain Diagnostics
and Thermography.
Sensitivity 100gms.
From A Comparison of Axonal Flares Reactions,
Pressure Algometry and Skin Temperatures to
Subjective Measures of Pain Strauss, Burns and
Sprague. Unpublished work. Brisbane Medical
School.
15
10 High Street Patients Profiles.

• A picture emerges of desperate patients
  suffering moderate to severe 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.

• Many of the chronic pain patients seen at
  10 High Street had tender points which when
  pressed on reproduced some or all of their pain.

16
Myofascial Tender Points

• Very few had had their Tender Points
  medically palpated prior to presentation.
• Many expressed surprise when their pain
  syndrome was reproduced by palpation.

17
Myofascial Tender PointsMostly Missed, Why?

• Almost all had never completed 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.

18
IASPs Journal PAIN

• Chronic Benign Intractable Pain Syndrome
  (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.

19
IASPs Journal PAIN
Non Specific Low Back Pain in a General Practice
setting is usually (80) associated with Trigger
Points.
Pain. Vol.. 37. 1989.

• 283 consecutive admissions to a comprehensive
  pain center The diagnosis made independently by
  a Neurosurgeon and a Physiatrist based on
  physical examination as described by Travell and
  Simons assigned a primary organic diagnosis of
  myofascial pain in 85 of the cases.
  
  Pain. Vol.
  26181-197 1986
  

20
TRIGGER POINTSThe Emerging Western Paradigm

• Can be thought of as

Pain Amplifiers
( T. McCarthy 1983 )
21
TRIGGER POINTS act as Pain Amplifiers

• where their activity
• enhances nociceptor input,
• eg. Osteoarthritis, Facet Joint Syndromes
  etc.
• augments sympathetic activity,
• eg. Reflex Sympathetic Dystrophy,
• Post Herpetic Neuralgia etc.

22
TRIGGER POINTS

• can be thought of as
• Pain Generators

where trigger points are the actual tissue
causing the pain state.
( T. McCarthy 1983)
I.e. Myofascial Pain Syndromes.
23
Trigger Point Postulates

• TrPs may be caused by sympathetically activated
  intrafusal contractions Spine. 1993 Oct
  118(13)
• The reduction in pain and TePs produced by a
  sympathetic blockade may be due to an improvement
  in microcirculation Pain, 33 2, 1988 May,
  161-7
• An endogenous opioid system may be the mediator
  for the decreased pain and improved physical
  findings following injection of myofascial
  trigger points with local anesthetic.
  Pain. 1988 Jan 32(1) 15-20

24
TRIGGER POINTSRxs Directed _at_ the Trigger Points
in the West

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

• Acupuncture

25
Cold Bi Syndromes

• According to the dictates of Traditional
  Chinese Medicine (TCM) Pain results from the
  blockage of Qi and blood.
• T.C.Ms Cold Bi syndromes include the
  majority of chronic musculoskeletal pain states
  where Tender Points are associated with
  coldness of the painful area.
• The T.C.M. treatment paradigm is to Remove
  the obstruction thus allowing warming and
  nourishing of the tissues.

26
Cold Bi Syndromes Rx Rationale- a Western
Translation

• Deactivate the Trigger Point thereby
  decrease the local/regional, aberrantly enhanced,
  sympathetic outflow activity associated with
  active trigger points.

27
Acupuncture for Pain

• This warming and nourishing of the tissues
  is addressed by the use of the Near and Far
  Acupuncture Technique.
• The Near and Far method is the most commonly
  used Acupuncture technique for the resolution of
  chronic pain syndromes in the Peoples Republic of
  China.
• (It is rarely used in the West)

28
The Near and Far Acupuncture Technique

• When the Near and Far technique is used to
  treat common pain states the treatment is aimed
  at resolving the tissue problem or reflex causing
  or maintaining the pain state.

29
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

As the provision of Analgesia in this context is
a secondary consideration Electro-Acupuncture
stimulation is rarely used in this context.
30
The Near and Far Acupuncture Technique

• Involves the use of both
• LOCAL
• and
• DISTAL
• Acupuncture points.

31
Local Points Where East Meets West

• Where there is a painful spot, there is an
  Acupuncture point from the Neijing- The Yellow
  Emperors Classic of Internal Medicine- 500 B.C.
• When pressed on the Patient winces, or suddenly
  starts and exclaims AAGH Is The POINT! From
  Acupuncture a Comprehensive Text Shanghai
  College of Traditional Chinese Medicine
• Ah Shi - Oh Yes! as the patients pain complaint
  is reproduced by palpation. Nanking College of TCM

32
Myofascial Trigger Points Where East Meets West

Both Western and TCM
West Only
Professor David Simons -Journal of
Musculoskeletal Pain
33
Local Points. AhShi - Oh Yes Trigger Points

• The Western equivalent of T.C.Ms AhShi point
  
• is the Trigger Point
• gt 70 of Local Acupuncture Points for Pain
  correspond to Trigger Points....R. Melzack
  Pain 3 Vol.. 3. 1977

34
Distal Acupuncture Points

• Are classical meridian Acupuncture points usually
  found below the elbow or knee.
• They are used for the treatment of many
  autonomically based diseases.
• In the pain Rx context Commonly used distal
  points are characteristically found in muscles
  often at the motor point. e.g. Li 4 - Hegu, Li 10
  - Shousanli.

35
Distal Acupuncture Points
Can be used to manipulate

• 1. the sympathetic nervous system.
• 2. the various Pain Gates

36
Acupuncture Sympatholysis

• Sympathetic vasomotor changes induced by
  manual and electrical acupuncture of the Hoku
  point visualized by thermography.
• Author Ernst M Lee MH
• Both manual and electrical acupuncture
  produced a generalized long-lasting warming
  effect, indicating reduced sympathetic activity
  (sympatholytic effect).
• In addition, electrical acupuncture induced
  a localized short-term cooling effect, indicating
  a transient segmental increase in sympathetic
  activity (sympathomimetic effect).
• 
  Source Pain, 1985 Jan, 211,
  25-33

37
Sympathetic vasomotor changes induced by manual
and electrical acupuncture of the Hoku point
visualized by thermography
Hoku / Hegu Point - Li 4 Perhaps the most
researched Acupuncture point. Motor point of
Abductor Pollicis. Used clinically to provide
analgesia, sympatholysis etc.
Face
Face
Hands
Feet
38
Acupuncture and SympatholysisThe Warming Effect
of Acupuncture on Nose Tip Temperatureon Cold
Nosed ( lt 34oC ) Patients c/o Headache and
AnxietyLi11 Li4, Bu 20 mins. Average
Temperature increase 2.26oC
T
0C
E
5
20
Mins
39
Acupuncture Sympatholysis

• Somatic sympathetic vasomotor changes
  documented by medical thermographic imaging
  during acupuncture analgesia. Authors Thomas
  D Collins S Strauss S
• 
  

This prospective study of 20 patients with neck
and arm pain measured finger temperature,
controlled by somatic sympathetic vasomotor
activity before and after needle acupuncture.
Responses were correlated with visual analogue
scale (VAS) of pain severity.
An association was found between pain relief and
reduced sympathetic vasomotor activity.
Clin Rheumatol, 1992 Mar, 111, 55-9
40
The Near and Far Technique for Chronic Pain
States Nanking 1978.
Distal Points Needle Technique

• The skin over the distal points is painlessly
  penetrated
• The needle is 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.
• Where sympatholysis is required the needle is
  gently manipulated and left in situ for 20
  minutes.

41
The Near and Far Technique for Chronic Pain
States Nanking 1978
Local 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.
• The needle is left in situ for 20 minutes.

42
Results of Acupuncture Rxusing the Near Far
Technique. Overview
Survey 1. 100 referred, 100 follow up.
Survey 3. NHMRC funded Survey 4. Brisbane Medical
School
43
Surveys Designed to elucidate the Patients
Opinion of their response to Acupuncture
Treatment.

• Following your Acupuncture Treatment
• Is your Pain More freq., same, less freq.,
  greatly less freq.,
  No pain / never
• Is your Pain More severe, same, less severe,
  very much less severe,
  no pain
• Has your range of movement improved, greatly
  improved, full, unchanged, not limited before
• General Questions Included Age, Drug Usage and
  Sleep Disturbance.
• Was Acupuncture of benefit?
• Same question format used for surveys 1, 2 3.

44
Survey 2.

• Follow up by mail at 6 months
• Patient Number 637
• Response rate 75, Yielding 478 responders.
• Total number of specifically treated complaints
  912
• Average number of treatments per patient 7.8
• Pain duration varied with type / site of pain.
• NB All private patients. (No Workers Compensation
  Involvement)

45
Survey 2. Overview of Results

• Greatly helped Very much less - no pain
  (Severity and frequency),
• Greatly decreased - nil medication, improved -
  normal sleep,R.O.M. increased
• NB Patients subjective opinion

46
Survey 2. Low Back Pain
136 cases Acupuncture of Benefit ? Yes 119 (
87.5 ) No 17 ( 12.5 ) Sleep Disturbance
Improved - Back to normal 88
47
Survey 2. Neck and Arm Pain

• Neck and Arm Pain ( Cervico-brachial syndrome )
  72 cases
• Average Number of treatments 7.4
• Acupuncture of Benefit? Yes 87
• Limitation of Movement- Improved 26, Greatly
  Improved 71
• Frequency of pain- Less 18, very much less - no
  pain 70
• Severity of pain- less 10, none - very much less
  77
• Sleep Improved 64, Back to normal 19
• Greatly helped with less than 5 treatments pain
  duration 2.1 years.
• Greatly helped with more than 5 treatments pain
  duration 5.4 years.
• Pain duration Helped group 7.5 years Greatly
  helped GP. 4.3 years

48
Survey 4.Brisbane Medical School Follow up _at_ 3 -
4 Years

• Duration of Improvement for those reporting pain
  relief.
• Less than 2 weeks.................................
  ...7.4
• 2 weeks - 3 months................................
  ...7.4
• More than 3 months...,,.........................
  16.7
• Still better at time of survey.................68.
  5

49
Survey 4.Brisbane Medical School Follow up _at_ 3 -
4 Years

• In what way had the Pain Improved
• It occurred less frequently....................9.2
  
• It was not as intense............................1
  1.1
• It was less intense
• occurred less Frequently.....................7
  9.7

50
From medline 1 of 3,300

• A prospective, randomized, double-blind
  evaluation of trigger-point injection therapy for
  low-back pain.
• Author Garvey TA Marks MR Wiesel SW
• Address Department of Orthopaedic Surgery, George
  Washington University Medical Center, Washington,
  D.C.
• Source Spine, 1989 Sep, 149, 962-4
• Abstract
• The efficacy of trigger-point injection therapy
  in treatment of low-back strain was evaluated in
  a prospective, randomized, double-blind study.
  The patient population consisted of 63
  individuals with low-back strain. Patients with
  this diagnosis had non-radiating low-back pain,
  normal neurologic examination, absence of tension
  signs, and lumbosacral roentgenograms interpreted
  as being within normal limits. They were treated
  conservatively for 4 weeks before entering the
  study. Injection therapy was of four different
  types lidocaine, lidocaine combined with a
  steroid, acupuncture, and vapocoolant spray with
  acupressure. Results indicated that therapy
  without injected medication (63 improvement
  rate) was at least as effective as therapy with
  drug injection (42 improvement rate), at a P
  value of 0.09. Trigger-point therapy seems to be
  a useful adjunct in treatment of low-back strain.
  The injected substance apparently is not the
  critical factor, since direct mechanical stimulus
  to the trigger-point seems to give symptomatic
  relief equal to that of treatment with various
  types of injected medication.