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8 Articles in Volume 5, Issue #2
Considerations in Treating Intractable Pain
Hospice Care Evolution
Myofascial Elements of Low Back Pain
Radiofrequency Neuroablation in Chronic Low Back Pain
State Pain Laws: A Case for Intractable Pain Centers Part III
Temporomandibular Joint Referred Pain
The ABC’s of Pain
Therapies for Chronic Pain and Fibromyalgia

Therapies for Chronic Pain and Fibromyalgia

New therapies, combining complementary/alternative medicine (CAM) approaches, and pharmacotherapy, provide options in treating chronic musculoskeletal pain.

Chronic musculoskeletal pain is the number one cause of disability in young adults and the number two cause of workplace absences and of visits to the family doctor. It costs North Americans over $80 billion per year. One of the most difficult conditions to treat is fibromyalgia syndrome (FMS). This pain syndrome is characterized by widespread body aching, associated fatigue, sleep problems, and occurs predominantly in females. It is estimated that FMS affects 2% of the general population.

To effectively manage this condition, a multidisciplinary team of healthcare professionals is required. The most effective approach is that of the four component theory originated by German physician Dr. Dietrich Klinghardt, MD PhD (see Figure 1).1 Dr. Klinghardt reasoned that medications such as anti-inflammatories, acetaminophen, muscle relaxants, etc. may all help to relieve pain in the short-term. However, if one gets to the root source (interference field) of the pain and resolves it, one gets the cure or long-term relief.

In this author’s own experiences in treating chronic pain and FMS patients for the past 20 years, it was found that the following therapies appear to be the most helpful in addressing each component illustrated in Figure 1. The following sections address each component in turn.

Structural Component

Structural cause of pain results from traumatic or overuse type injuries to the body’s musculoskeletal system. Traditional approaches vary from surgery for severe fractures to chiropractic/osteopathic manipulation for restricted joint movement. Properly prescribed and supervised exercise can stretch out tight muscles and strengthen weakened ones. Such exercise can be further enhanced with computer-assisted feedback (called surface EMG). This allows for much more individualized and activity-specific correction of subtle muscle imbalances that often perpetuate the pain state.

Figure 1. The four components of chronic pain.1

One commonly overlooked cause for persistent structural pain is that of weakened ligaments. Unlike muscle, ligaments (which are the fibrous tissues that join one bone to another) have very limited blood supply and tend to heal very slowly or incompletely. Also ligaments cannot contract and cannot be “exercised." A common cause of low back pain are weak sacroiliac ligaments at the base of the spine. These cannot be diagnosed by MRI scans and treatment is very much dependent on the manual skills of the treating therapist. For restricted or “stuck" joints, manipulation or mobilizing of the joint often restores normal movement. However, the joint with ligament injury and laxity remain unstable and the instability would only be perpetuated by repeated manipulation.

This author has found an older orthopedic medicine technique known as prolotherapy,2,3 to be helpful in such cases. This involves injecting mostly natural substances (such as dextrose and/or glucosamine, phenol, fish oil extracts) into the ligaments once every 4-6 weeks. By doing so, the ligaments are “challenged" to repair and heal back more fully. The typical patient requires from 2 to 6 injections for long-term relief of their back pain. One recent study suggests that even the needle itself at the bone-ligament interface may provide the specific mechanism of action.4 Emerging research includes human growth hormone (humatrope) intraarticular injections.

Such injections should only be done by physicians with special training (for example, through the Canadian/American Associations of Orthopaedic Medicine; www.aaomed.org). Prolotherapy works best when combined with appropriate short-term bracing (serola sacroiliac belt), avoidance of anti-inflammatories, and physiotherapy-directed exercises to enhance core stability of the spine. Failing that, surgical fusion would be a final option.

Case Report 1: Polio patient with chronic low back pain improved with prolotherapy.

A 45 year-old, married computer worker with diffuse pain worse in the low back was seen in Nov. 2000. Clinical exam revealed old polio (atrophic small flail right arm and shorter, thinner left leg; see Figure 2), 18/18 tender points (TePs) and marked tenderness in the left sacroiliac (SI) region. 2+ laxity noted with the shear test for SI instability. Nerve root tension tests were negative and EMG revealed only chronic neurogenic changes. Bloodwork and bone scan were negative for active sacroilitis. After trials of physiotherapy, chiropractic, orthotics (leg-length correction), prolotherapy injections — with P2G (phenol-glycerine-glucose) and lidocaine — were done to the SI ligaments on a monthly basis.

Case 1.
Outcome measures
Pre Rx Post-6th Rx (06/01)
VAS (visual analog scale for pain) 8/10 4/10
Short-form McGill Questionnaire 24/45 19/45
Pain Disability Index 44/70 24/70
Oswestry LBP score 37/50 15/50
Algometry FMS avg. pain 2.13kg 3.0 kg

Figure 2. Polio patient with chronic low back pain.

This patient returned 2 years later for a tennis elbow complaint and was pleased to report continued back pain relief.

Biochemical Component

The body’s own biochemistry may perpetuate chronic pain include hormonal (hypothyroidism, menopause, diabetes) and hematology/ immune system (anemia, HIV, cancer etc.) deficiencies. After doing tests to rule out such diseases, one must also look for poor dietary habits (excess intake of processed carbohydrates, junk food, caffeine) and intake of toxins (smoking, chemical and environmental pollutants).

It is useful in the motivated patient to get appropriate dietary counseling from a registered dietician and, for more complex cases, to see a registered naturopathic doctor (ND). The latter professional has specialized training in the use of herbals, homeopathics,5 vitamins, other supplements,6 and dietary strategies.7,8

Detoxification approaches may include biological terrain testing, hair mineral analyses and intravenous therapies. Since many natural products also interact with drugs and chemotherapy, it would be preferable to see a naturopathic doctor who also has had training in traditional medicine. This would give a more balanced — and potentially safer — integrative approach.

Case report 2: Fibromyalgia patient can golf again after naturopathic therapies and oral guaifenesin (Dr. St. Amand protocol; see caption of Figure 3).

A 54 yr-old married retired left-handed IBM consultant had FMS for 15 years. Risk factors included childhood growing pains and hypermobility; left elbow fracture and right knee arthroscopy for osteoarthritis. Her mother had Charcot-Marie-Tooth disease (self-tested was EMG negative). She had extensive dental work and rows of amalgams and root canals. Hypertension for 2 years. Her best exercise tolerance was going on a treadmill at 1.9 mph for only a few minutes.

Pre-treatment (Jan 2002):

18/18 TePs. VAS 9/10. FIQ:71.7/90. This patient could not write and could only climb stairs one step at a time. She could not drive because her neck was stiff and she often felt dizzy. She had chronic constipation and severe migraines 2 to 3 times a month.

Initial treatment:

included naturopathic evaluation and general detoxification (homotoxicology approach; see Figure 3). After a month of detoxification, she started guaifenesin capsules 300mg/ day. This was titrated up to 900 mg BID.

July 2002:

18/18 TePs. VAS 2-8/10. FIQ:48.4/90. Overall, she felt 35% improved and was able, for the first time in years, to play 5 rounds of 9-hole golf. She continued on oral guaifenesin and salicylate avoidance.

January 2003:

13/18 TePs. VAS 1-7/10. She could carry heavy laundry upstairs and exercise on a treadmill at 3.2 mph for 30 minutes, 3 times a week. She was able to do bicep curls with 7.5 lbs barbells.

September 9 2003:

13/18 TePs. VAS:1-6/ 10. FIQ: 12/90. She played 35 rounds of 18-hole golf in the past summer. She regularly did heavy gardening and could sweep her driveway with a heavy broom. She only had light headaches 1 to 2 times a month. A phone call check on April 21, 2004 revealed continued significant symptom reduction and a high level of function.

The use of CAM must be monitored for adverse effects and potential interactions with medications. As a general rule of thumb, all herbal products should be stopped prior to any surgery or extensive and/or deep soft tissue injections due their blood-thinning effect. Supplements may also interfere with chemotherapy and radiation used in oncology.

Figure 3. Treating naturopath using electrodermal acupuncture technology to assist in this patient’s detoxification. Paul St. Amand, MD is an endocrinologist at UCLA who has published on effective FMS treatment with guaifenesin promoting renal excretion of inorganic phosphate (in his text: “What your doctor may not tell you about fibromyalgia" ISBN 044667512-1.)

Psychospiritual Component

This component of pain includes the stress from physical and/or emotional traumas. Some cases of chronic pain have predisposing factors such as previous child abuse, sexual abuse, dysfunctional family setting, financial, or work-related stressors. Post-traumatic stress disorder after life-threatening or severe physical trauma will also perpetuate chronic pain. Newer techniques to improve sleep and reduce anxiety and stress states include neurotherapy.9,10 This therapy utilizes computer-assisted feedback of brainwave activity combined with visual and auditory input signals to entrain the brain into a more relaxed state. It can also be used to induce higher frequency (beta-wave) brain activity to improve concentration (or counteract “fibrofog" in fibromyalgia patients). Such approaches work effectively when combined with good counseling including cognitive-behavioral therapy.11 More information on this therapy is available from the Association for Applied Psychophysiology and Biofeedback (www.aapb.org). Meditation and intercessory prayer have also been studied and promoted for healing in chronic pain and disease.12,13

Case Report 3: Fibromyalgia patient with “brain fog" improves with neurotherapy/biofeedback.

A 48 year-old married dog-breeder developed FMS with chronic pain, cognitive difficulties, severe depression and generalized anxiety after a motor vehicle accident in 1999. After numerous therapies and medications, she was told that she had reached maximum recovery. She started neurotherapy/ biofeedback (see Figure 4). This patient had a total of 20 sessions from March to September 2003.

After 10 sessions, she estimated 75% improvement. She noted that “I can laugh. I am awake again and feel as if I am reborn." After 20 sessions, she was 95% improved and noted that whatever was left in terms of her concentration deficits was just what “people normally face at this age of life." She could socialize more and do all kinds of activities with her son and husband.

Figure 4. Patient undergoing neurotherapy/biofeedback therapy.

Case 3.
Outcome measures
Pre-Rx Post-Rx
VAS pain score 7/10 2/10
Beck anxiety score 11/63 2/63
Beck depression 26/63 8/63
Perceived deficits scale 69/80 22/80
Fatigue severity scale 42/63 13/63
Fibromyalgia Impact
Questionnaire
65/90 19/90

Neurological Component

This pain component includes actual changes in peripheral (nerves) and central (brain) nervous system function that leads to perpetuation of pain even though the original injury or insult has resolved. This phenomenon is referred to as “central sensitization" which may be detectable in upcoming technologies such as functional MRI scanning (presently being used in research laboratories).14,15 Medical treatment for this includes the use of oral medications such as anti-epileptic drugs (Neurontin, Topamax),16 long-acting opioids (Contins, Duragesic),17,18 cannabinoids (Cesamet, Sativex),19,20 and muscle relaxants (Lioresal, Zanaflex).21 The limitation of such oral medications include side-effects such as nausea, drowsiness, and dry mouth. One approach to minimize side-effects and drug tolerance is to combine them with custom-made (compounding pharmacy) topical pain gel, cream or spray. These are applied directly to the site of pain and thus bypass the gastrointestinal tract. For example, topical ketamine (an NMDA receptor antagonist) works well for superficial burning pain. This author usually prescribes ketamine mixed with an anti-inflammatory and local anesthetic topically for neuropathic allodynic pain.

Figure 5. Botox: mechanism of action.

5a. The Botox molecule on the left binds to the membrane of the nerve terminal. Normally, the transmitter acetylcholine is stored in round vesicles that are released into the nerve-muscle junction. By doing so, the transmitter will stimulate the underlying muscle to contract.
5d. After binding, the Botox molecule is swallowed up into its own vesicles within the nerve. The bond joining the heavy and light chains of the Botox molecule is broken as the vesicle becomes more acidic.
5c. The light chains then move out of the vesicles and bind to a protein on the inner nerve membrane. This blocks the release of acetylcholine for a prolonged period of time lasting around 3 months.

Perhaps the most exciting approach to reduce both peripheral and central pain sensitization is Botulinum Toxin-A (Botox). This highly purified protein-neurotoxin is extracted from the “botulism" bacteria. The molecule, when injected into muscle, is taken up by nerves and blocks them from releasing the transmitter acetylcholine. This produces a temporary but prolonged relaxation of muscle and typically lasts about 3 months. The mechanism of action is illustrated in Figure 5.

Prolonged muscle relaxation and pain relief occurs as a result of this acetylcholine block.

The nerve-muscle junction also returns back to normal function (as in Figure 5a) after 3 to 4 months. Botox was initially developed in the early 1980’s for treating strabismus (cross-eyedness). Observations then led to its use in blepharospasm (twitching eyelids). From those patients, wrinkles were noted to be improved as well. By the mid 90’s, people getting cosmetic Botox then reported their migraines were relieved. This then led to a flurry of research on Botox for chronic pain.

Chronic muscular pain can now be relieved for a 3-plus months period with one treatment of Botox. The current theory on painful muscle “trigger points" is that they are caused by an excessive release of acetylcholine. By blocking this release, Botox helps to break the chronic pain cycle. Several randomized controlled studies support the use of Botox for migraine,22 tension headaches,23 low back pain,24 myofascial pain,25 whiplash,26 and tennis elbow.27 This author was the first to report Botox injections helpful in fibromyalgia patients with migraine and low back pain.28 Now lab research has documented that it also inhibits pain transmitters (e.g. substance P,29 calcitonin gene-related peptide,30 and glutamate31). Through intradermal (skin) injections, the severe burning pain of “shingles" and trigeminal neuralgia can also be relieved.32 Botox appears to be safe.33 Since the early 1980’s, there has been over 3 million injections done worldwide (in over a million people) without any documented case of an anaphylactic (severe allergic) reaction. Botox has all the advantages of longer pain relief without the side-effects of cortisone injections or more invasive surgery.

Figure 6. Botox injection for low back pain.

Case Reports 4a, 4b, 4c: Efficacy of Botox in Neurological Pain

Case Report 4a. ICU nurse with Botox is able to continue full-time work.

Case 4b. Pre-injection One month post-3rd
Surface EMG RMS
amplitudes (uV):
left right left right
Frontalis        
• sitting at rest 2.24 3.99 1.44 0.96
• cervical lat. flex 6.97 4.54 1.51 0.98
• cervical rotation 6.84 6.73 1.90 1.34
Trapezius        
• standing at rest 15.07 5.47 5.20 2.24
• cervical rotation 5.36 4.12 2.44 3.10
Case 4b.
Outcome measures
Pre- injection 1 mos. Post-3rd injection
VAS pain score 7/10 4/10
Headache Disability index 92/100 84/100
Headache Impact test 68/78 58/78
Vernon-Mior questionnaire 33/50 28/50

A 46-year-old single mother and RN had a pituitary brain tumour excised in 1988. She was placed on hormone replacement therapies, gained 176 lbs in one year and developed widespread tenderpoints. She underwent her first Botox treatment in Jan 2002 and her eighth in August 2004 (see Figure 6). She reported that with Botox, she can: work full-time, walk upstairs, sleep better, be more capable of gardening and housework. She noted less fatigue, irritability (with her teenage son), depression, and social withdrawal. Pre-treatment pain scores: VAS 7/10. FIQ 89/100; while her post-8th injection (500 units) pain scores were: VAS 4/10. FIQ 44.3/100.

Case Report 4b. Patient with 12 operations for headache gets relief with Botox and adjuvant medications.

A 53-year-old woman had post-traumatic head and upper facial pain after a car accident in 1989. CT/MRI scans were normal. Over the subsequent 10 years, she had 12 surgical procedures including open C2 ganglionectomy, cervical facet rhizolyses x 3, C2 neurotomy (dorsal ramus medial branch), right temporal artery excision, bilateral supraorbital nerve resections and percutaneous microballoon compression of the gasserian ganglion.

Despite palliative nerve blocks from the referring anesthesiologist, she still complained of daily bifrontal headaches radiating to the upper shoulders and dorsal neck. Topamax was added to medications which included Paxil, Oxycontin, Stemetil, Amitriptyline, Ibuprofen, Losec. Physical examination revealed hypoesthesia in the forehead and C2 distribution. Tenderness was most noted on the upper trapezii, frontalis and paracervical muscles. Botox-A injections (see Figure 7), administered to the pericranial (frontalis, corrugator, procerus, temporalis) and trapezii muscles, showed good response and was supported by outcome measures and surface EMG recordings.

Her FIQ score before Botox was 51.4/ 90. One month after her second last Botox injection (Dec 2003), the FIQ was down to 14.8. With Botox, she reported that she can go shopping and carry 10 lbs (milk, potatoes), do laundry, dishwash, and stand one hour to cook. Her husband observed that she can do ironing without complaining of pain. Further injections have been carried out every 3 months for 11 sessions to date without any significant complication. She estimates it alleviates pain by 75% and is able to reduce and stabilize her oxycontin dose.

Figure 7. Botox injection for headache and neck pain. Figure 8 A. Intradermal injections done with a bent 30g ½" needle. Figure 8 B. Temporary right facial weakness after 2nd set of injections.

Case Report 4c. Intradermal Botox relieves neuropathic facial pain.

A 63-year-old business woman presented with a 20 year history of right-sided trigeminal neuralgia. Neurosurgical decompression done 18 years ago provided 5 years of pain relief. Fluoroscopic injections done 13 and 12 years ago were unsuccessful, with the latter complicated by spinal meningitis. Treatments also included courses of dilantin, tegretol. Despite gabapentin 2400 mg/ day, she complained still of severe burning pain in the right cheek and “screw-like" pain in the palate. Physical examination revealed cutaneous allodynia in right maxillary and mandibular divisions. No Horner’s syndrome. Facial EMG studies were normal including blink reflexes. Intradermal lidocaine injections (12-05/03) provided 6 hours of good pain relief. 60 units of BTX-A was then injected (1:1 dilution) intradermally with injection sites 1 cm apart into the cheek and jaw (V2 & V3 distribution; see Figure 8).

Case 4c. Outcome measure Pre-
injection
6 wks. Post- injection
VAS pain score 7/10 1/10
Neuropathy pain scale 65/100 16/100

She reported for the first time in years that she was able to, without pain, brush her teeth, chew food, garden and sit in the jeep with the window down. She had 100 units of BTX-A administered on 19-08/03 with further pain relief and temporary right facial weakness. She reports that “I would certainly recommend it. It’s made a difference in my life."

Further information about Botox therapies can be found at www.MusclePainRe lief.ca. As the chair for the Canadian national steering committee on Botox for painful muscle spasm, this author is pleased to report that guidelines are being developed to ensure consistency in dosage, technique and follow-up. Botox — when combined in a four-component integrative approach — should further enhance the armentarium for reducing suffering and disability in chronic pain patients.

Last updated on: January 4, 2012
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