Pain Treatment—Then and Now
I was lucky to get to know Janet Travell, MD, during the last 3 years of her life. We didn't communicate a lot, but I got the chance to see the incredible intelligence and commitment she had to patients. We mostly talked about the myofascial pain syndrome (MPS). She told me that it was her father who got her moving in that direction.
While I didn't know her very well, I was blessed to have a chance to talk with one of my medical heroes! People who have read my writings know I have done a lot of work with MPS, especially in association with various types of pain and acute and chronic tension-type headaches. I was very happy to have the chance to talk to her about my thoughts regarding the pathophysiology of some of these diatheses.
Dr. Travell's treatment of President John F. Kennedy was exceptional—treating him in an interdisciplinary way using the best medications available at the time. As noted in Dr. Forest Tennant's review, Dr. Travell's understanding of pain management was deep, and she used the available drugs both appropriately and for excellent reasons. For example, the treatment of JFK included hormones (testosterone and others). Knowledge of which hormones help to decrease pain, as discussed by Dr. Tennant, is not something that is widespread even today. Although the use of hormones did help with pain, it was also necessary to keep JFK alive and basically healthy (as well as could be expected with the autoimmune issues that were ongoing).
While it is certainly true that chronic peripheral pain can become centralized secondary to, among other issues, neuroplastic changes in the spinal cord (wide dynamic neurons) and in the brain, most of the medications used today to treat neuropathic or centralized pain did not exist when Dr. Travell was treating JFK—leaving her with only pain medications available. The drugs of choice today include anticonvulsant medications such as pregabalin (Lyrica), or even serotonin norepinephrine reuptake inhibitors like duloxetine (Cymbalta) and others, such as venlafaxine. These options were certainly not available 60+ years ago. Of the medications available to Dr. Travell, we know that meperidine and codeine (not used much at all today—if at all) were used for years for acute pain. We now understand (but probably not in the 1950s) that methadone has about a 10% N-methyl-d-aspartate receptor inhibition, which would have been helpful for analgesia of centralized pain.
Dr. Travell's use of sleeping aids (barbiturates) was both necessary, as well as a drug of the time. The same can be said for the meprobamate (another barbiturate) and chlordiazepoxide (Librium) that Dr. Travell used for anxiety and as muscle relaxants. Her use of procaine injections was most likely into myofascial trigger points, a most helpful treatment that continues to be used today. The stimulant may have been used for both countering the sedative effect of the barbiturates and opioids, as well as to help decrease pain in JFK's central sensitization pain disorder. The use of gamma globulins in the president, who was dealing with significant hormonal deficiencies, was necessary. The use of vitamins B and C were also useful and certainly wouldn't harm the president.
Finally, and most impressively, Dr. Travell treated more than the symptoms of pain and hormonal dysfunction. Her use of physical/physiatric measures (application of a heel lift, back brace, and corset) was very much needed. Even more importantly, Dr. Travell knew then what we know now—physical exercise is necessary to maintain a number of physiological functions as well as to help decrease pain.
If JFK was to be treated today, several changes would be made to the treatment plan. Regarding medication, the use of an extended-release opioid could be used. Methadone, of course, has an extended half-life, but many physicians don't know how to use it well. At issue is using extended release pain medications to make pain relief easier to obtain without "clock watching," which may include the use of a fentanyl patch or even oxycodone (Oxycontin).
Other medications for use as stimulants may not be needed with good pain management, but there continues to be methylphenidate for use, as well as amantadine, and others. There would be no issue with continuing to use procaine for injections into the myofascial trigger points. Lidocaine and benzocaine are also used.
Probably the biggest medication changes would deal with the hormones needed to address the autoimmune dysfunction JFK was dealing with. Transdermal testosterone by gel or patch is now common. Synthroid, along with liothyronine (Cytomel, faster acting) would be an appropriate treatment for his thyroid difficulties.
As Dr. Tennant noted, real cortisone for oral use was not developed until 1950. Today, hydrocortisone (Cortef) can be given orally for adrenal insufficiency. Also, today, of course, prednisone is readily available. The main issue here is that without cortisol and other adrenal hormones, the president wouldn't have been able to persevere either during the war, on a PT boat, or as president.
Muscle relaxants are different—meprobamate and chlordiazepoxide wouldn't be used today as true muscle relaxants. Probably the best drug for the long-term muscle spasm would be tizanidine (Zanaflex), an α-2 adrenergic agent. The use of the benzodiazepines as true striated muscle relaxants is not felt to be appropriate as the amount needed to actually induce striated muscle relaxation is far more than would be used for anxiolysis, and can induce significant sedation.
Sleeping aids, if needed, would today not consist of a barbiturate, but would be one of the newer drugs that interact with γ-aminobutyric acid–benzodiazepine receptor complexes, such as zolpidem (Ambien) or eszopiclone (Lunesta).
Bottom line—Dr. Travell treated President Kennedy in a highly appropriate fashion, using tools that most physicians today wouldn't know how to use, and even in ways they may not have been able to fathom. I do believe that Dr. Travell knew or intuited various things about drugs and hormones that we now understand better and more deeply. The fact that her treatment plan was so effective is a function of her exceptional skill as a physician at a time when physicians knew far less than we know now.
Dr. Travell was a very incredible physician as well as a person. I feel honored to have known her even for the little time I did.