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.

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

10 High Street: Treatment Surveys

Survey Number % ofResponders

Follow Up Method

1 124 100% 6/52 Telephone

2 637 75% 6/12+ Mail

3 2083 55% 12/12+ Mail

4 365 35% 3-4 Years Mail

10 High Street. Pain State Distribution & Age

Breakdown of 1146 Patient’s Pain Syndromes. From survey 3.

39858

39361

29756

24052

23958

18458

0 100 200 300 400

Neck

Back

Shoulder

Headache

CBS

Sciatica

10 High Street. Pain Severity

0

5

10

15

20

25

30

1 2 3 4 5

97% Could be regarded as having severe pain

No Pain

From Survey 4. Brisbane University School of Medicine

Unbearable Pain

Pain Severity 10 High Street Compared with General Community Pain Population

0

5

10

15

20

25

30

35

40

1 2 3 4 5

10 High St.

General CommunityPain Population

%

No Pain

From Survey 4. Brisbane University School of Medicine

The Prevalence of Pain Complaints in a General Population: An Australian Study

Unendurable Pain

10 High Street. Reason for Presentation

Other forms of treatment had not helped: 63%

“I’d have tried anything if I thought it would help”: 61%

From Survey 4. Brisbane University School of Medicine

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.

10 High Street 137 Back Pain Patients’ Profiles.

55% NSAI’s / Analgesics (currently using on presentation)

16% Epidurals,

36% Chiropractic,

24% Physiotherapy,

From Survey 2. 478 Responders. Follow up 6 months, mail survey. 75% response. From Survey 2

Total number of health professionals consulted was 380.

Average pain duration was 6.8 years.

72% c/o disturbed sleep.

8% Laminectomy/Fusion.

10 High Street Back Pain Patient’s 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.

Analysis of 21 consecutive unilateral back pain patients

Average age 57 years

Average VAS = 5 [ 0………X………10cms ]

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 females, 9 males

Analysis of 21 consecutive unilateral back pain patients Temperature measurements of tender points

compared to contralateral anatomic site.

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 >95%)

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*.

Temperature was measured with an InvotechC600M Biotherm Infrared thermometer. Sensitivity 0.1 0C

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 > 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*.

Analysis of 21 consecutive unilateral back pain patients The Mean Pressure Threshold

Female Tender Points was 1.84 kg/cm2. (N>3.8)

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*.

Male Tender Points was 2.56 kg/cm2 (N>5.6)

Threshold for whole group Tender Points = 2.4 kg/cm2.

Pressure Threshold Meter by Pain Diagnostics and Thermography. Sensitivity 100gms.

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.

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.

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.

IASP’s 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.

IASP’s Journal “PAIN”

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. 26:181-197 1986

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

TRIGGER POINTSThe Emerging [Western] Paradigm

Can be thought of as

“Pain Amplifiers”

( T. McCarthy 1983 )

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.

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.

Trigger Point Postulates

• TrPs may be caused by sympathetically activated intrafusal contractions Spine. 1993 Oct 1;18(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

TRIGGER POINTSRx’s Directed @ the Trigger Points in the West

• Spray and Stretch

• Ischaemic pressure massage (Shiatsu)

• Injection ( Local Anaesthetic, etc. )

• Dry Needling (Superficial, Deep, +/-multiple)

• Acupuncture

Cold Bi Syndromes: According to the dictates of Traditional Chinese According to the dictates of Traditional Chinese

Medicine (TCM) Pain results from the blockage of Qi and Medicine (TCM) Pain results from the blockage of Qi and blood. blood.

T.C.M’s T.C.M’s Cold Bi syndromesCold Bi syndromes include the majority of include the majority of chronic musculoskeletal pain states where “Tender chronic musculoskeletal pain states where “Tender Points” are associated with coldness of the painful area. Points” are associated with coldness of the painful area.

The T.C.M. treatment paradigm is to “Remove the The T.C.M. treatment paradigm is to “Remove the obstruction thus allowing warming and nourishing of the obstruction thus allowing warming and nourishing of the tissues.” tissues.”

Cold Bi Syndromes: Rx Rationale- a Western Translation

““Deactivate” the Trigger Point Deactivate” the Trigger Point

thereby decrease the thereby decrease the

local/regional, aberrantly local/regional, aberrantly

enhanced, sympathetic outflow enhanced, sympathetic outflow

activity associated with active activity associated with active

trigger points.trigger points.

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)

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.

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.

The Near and Far Acupuncture Technique

Involves the use of both

LOCALand

DISTAL

Acupuncture points.

Local Points Where East Meets West

• “Where there is a painful spot, there is an Acupuncture point” from the Neijing- The Yellow Emperor’s 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 patient’s pain complaint is reproduced by palpation. Nanking College of TCM

Myofascial Trigger Points Where East Meets West

Examination Difficulty Diagnostic value

Spot Tenderness + ++Jump Sign + +Pain Recognition ++ +++Palpable Band +++ ++++Referred Pain +++ +Twitch Response ++++ ++++

Both Western and TCM West Only

Professor David Simons -Journal of Musculoskeletal Pain

Local Points…. AhShi - Oh Yes

Trigger Points

The Western equivalent of T.C.M’s AhShi point

is the

“Trigger Point”

> 70% of Local Acupuncture Points for Pain correspond to Trigger Points………....R. Melzack Pain 3 Vol.. 3. 1977

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.

Distal Acupuncture Points

1. the sympathetic nervous system.

2. the various “Pain Gates”

Can be used to manipulate

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, 21:1, 25-33

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

Acupuncture and Sympatholysis

The Warming Effect of Acupuncture on Nose Tip Temperatureon Cold Nosed ( < 34oC ) Patients c/o Headache and Anxiety

Li11 + Li4, Bu 20 mins. Average Temperature increase = 2.26oC

-4

-3

-2

-1

0

1

2

3

4

5

6

T

5 20 Mins

0C

E*

Acupuncture & Sympatholysis

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

Clin Rheumatol, 1992 Mar, 11:1, 55-9

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.

The Near and Far Technique for Chronic Pain States:

Nanking 1978.

• 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.

Distal Points Needle Technique

The Near and Far Technique for Chronic Pain States: Nanking 1978

• 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 patient’s 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.

Local Points

• A fine 30 - 32 Gauge needle is painlessly inserted through the skin over the active trigger point/points.

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

Survey Number % ofResponders

Follow Up Acupunctureof Benefit?

1 124 100% 6/52 Yes 84%

2 637 75% 6/12+ Yes 88%

3 2083 55% 12/12+ Yes 87%

4 365 35% 3-4 Years Yes 85%

Surveys: Designed to elucidate the Patient’s 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.

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)

Survey 2. Overview of Results

0

10

20

30

40

50

60

70

80

Back

Headache

AnxietyC.B.S.

Knee

SciaticaNeck

HelpedGreatly Helped

Greatly helped = Very much less - no pain (Severity and frequency),

Greatly decreased - nil medication, improved - normal sleep,R.O.M. increased +++

NB Patient’s subjective opinion

%

Survey 2. Low Back Pain

0

10

20

30

40

More Less V. MuchLess

No Pain

Pain Freq.

Pain Sev.

136 cases

Acupuncture of Benefit ? Yes 119 ( 87.5% ) No 17 ( 12.5% )

Sleep Disturbance Improved - Back to normal 88%

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

Survey 4.Brisbane Medical School Follow up @ 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%

Survey 4.Brisbane Medical School

Follow up @ 3 - 4 Years In what way had the Pain Improved:

• It occurred less frequently....................9.2%

• It was not as intense............................11.1%

• It was less intense &

occurred less Frequently.....................79.7%

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, 14:9, 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.