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Pain Management

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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. – PowerPoint PPT presentation

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Title: 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

7
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.)

8
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!

9
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.

10
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

11
Location of most severe pain The Epidemiology
Pain An Australian Study
  • As of Pain States declared

12
Intensity The Epidemiology Pain An Australian
Study 45 can be regarded as suffering from
severe pain


13
Duration The Epidemiology Pain An Australian
Study 91 have Chronic Pain
  • Time since first occurrence of Pain State

14
Frequency The Epidemiology Pain An Australian
Study53 Daily or constant
  • Frequency of Pain Occurrence as a

15
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

16
Health Professional Consulted.
  • 70 visited a Health Professional
  • 30 no treatment or self treatment
  • The Epidemiology Pain An Australian Study

17
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

18
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)

19
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.

20
10 High Street. Pain State Distribution Age
  • Breakdown of 1146 Patients Pain Syndromes


21
10 High Street. Pain Severity97 Could be
regarded as having severe pain
  • No Pain
    Unbearable Pain


22
10 High Street Compared c General Pain Population
  • Comparison of pain severity

23
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

24
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)

25
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


26
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.

27
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.

28
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.

29
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.

30
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)

31
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.

32
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.

33
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.

34
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.

35
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

36
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.

37
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.)

38
The Near and Far Acupuncture Technique
  • Involves the use of both
  • local
  • and
  • distal
  • Acupuncture points.

39
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

40
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

41
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

42
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.

43
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

44
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.

45
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.

46
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.

47
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.

48
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.

49
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)

50
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)
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