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10 Articles in Volume 17, Issue #10
A Guest Editorial on Counterfeit Pain Medication: The Other Epidemic
A Model to Incorporate Functional Medicine into Chronic Pain Care
Chronic Pain and Substance-Related Disorders
Getting at the Root of Opioid-Induced Constipation (OIC) with an Osteopathic Approach
Inside FDA's Guidance on Generic Abuse-Deterrent Opioids
Neural Pathway Pain — A Call for More Accurate Diagnoses
Pain Care in a Natural Disaster
Pharmacological Interventions in Sport-Related Concussion
The Internet of Medical Things
What Type of Withdrawal Symptoms from Tramadol Might a Patient Experience?

Neural Pathway Pain — A Call for More Accurate Diagnoses

In the treatment of chronic pain, the author argues that a patient’s physical and emotional history may play a more significant role in long-term outcomes than expected.
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  • History of several neural pathway-induced syndromes over a lifetime, such as headaches, migraine, irritable bowel syndrome, interstitial cystitis, neck or back pain, pelvic pain, fatigue, insomnia, anxiety, and depression
  • Early-life trauma
  • Personality traits of people pleasing, self-criticism, lack of self-compassion, lack of assertiveness, perfectionism (increased pressure upon oneself may further activate the danger/alarm mechanism)
  • Pain that:
  • worsens over time
  • spreads to new regions of body
  • shifts from region to region
  • turns “on and off”
  • has an onset upon awakening
  • worsens with increased stress / improves with less stress
  • radiates to areas that do not conform to structural norms
  • is often bilateral in nature.

Once aware of these patterns, clinicians may be able to determine which patients have neural pathway-related disorders as opposed to purely structural causes. Some patients may have a combination of the two.

Step-by-Step Approach

With a clear and accurate diagnosis, treatment of neural pathway pain may involve components of: cognitive-
behavioral therapy; mindfulness/meditative processes; and acceptance and commitment therapy. There is, however, one caveat. While these modalities may often be used to treat chronic pain, practitioners may tend to apply them under a premise that the pain is caused by physical problems in the body. However, these types of interventions take on an entirely different meaning when the premise is changed. With the understanding that there is no structural disorder—ie, the pain is generated by neural pathways in the brain, the goal changes from pain management to pain elimination. Primary steps in this process include:

  • Educating the patient about the nature of pain and the role of the brain in generating neural pathway pain (ie, understanding that there is no physical damage and that recovery is possible)
  • Reducing activation of the danger/alarm mechanism in the patient’s brain by using cognitive methods to reduce fear of pain (eg, pain may be reframed as “unharmful sensations produced by the brain”)
  • Encouraging increased activity and resumed normal activities without fear of pain or of injury; making life changes that are necessary to promote safety and well-being; and increasing enjoyment in daily life
  • Helping the patient to process emotions that may have led to the painful syndromes (eg, engaging in exercises that allow the recognition, experience, expression, and processing of emotions that may have been avoided in the past (eg, anger, guilt, sadness, and compassion).14

A Case Example

When Casey was 14-years-old, he developed severe abdominal pains that progressed to the point of him being unable to attend school or participate in daily activities. Over the next three years, he underwent numerous medical tests, including CT, MRI, EGD, colonoscopy, and motility studies. He was under the care of a gastroenterologist, a surgeon, and a pain management specialist at a university hospital. He also had an exploratory laparoscopic procedure and injections for pain control. However, there was no evidence to support any physical injury to account for the severe pain. His pain was constant and, at times, flared to levels high enough to cause syncopal episodes.

At age 17, Casey presented at the practice of one of the authors (AG) that specializes in the treatment of neural pathway or mind-body pain. A functional MRI found severe abnormalities in the resting state of Casey’s brain (see Figure 1, previous page). An evaluation further confirmed that Casey had no physical cause for his pain complaints, leading the clinicians to conclude that Casey’s pain was most likely due to neural pathways. It was explained to Casey that his pain was very real, but also that the most important aspect of his recovery had already taken place: he had been accurately diagnosed as having brain-generated, rather than tissue damage-generated pain.

By changing his understanding of the cause of the pain, Casey was able to reduce his fear of the symptoms. The intervention allowed his danger/alarm mechanism to turn off, which in turn, led to elimination of pain.

After three months, Casey reported a complete recovery from the abdominal pain and a repeat fMRI showed normal function (see Figure 1). He returned to school and resumed his usual activities.

Supporting Research

The author’s clinical experience, combined with the research noted herein, suggests that the neural pathways responsible for the majority of chronic pain may be reversible.15-16 Emerging data supports this view. Two outcome studies of individuals with chronic back pain and fibromyalgia demonstrated dramatic pain reductions using the approach described above.17-18

Additional results of a small randomized, controlled trial showed that a mind-body approach was more effective than treatment as usual.19 In a larger study,20 230 patients diagnosed with fibromyalgia were placed in one of three groups:

Last updated on: December 7, 2017
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Pharmacological Interventions in Sport-Related Concussion