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Naturally, We’re Rolling with It: Complimentary and Alternative Medicine in SCI Pain Management

Naturally, We’re Rolling with It: Complimentary and Alternative Medicine in SCI Pain Management. Timothy Hudson, MD, MHA , LAc , FAAPMR Penn State Hershey Medical Center. No disclosures.

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Naturally, We’re Rolling with It: Complimentary and Alternative Medicine in SCI Pain Management

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  1. Naturally, We’re Rolling with It:Complimentary and Alternative Medicine in SCI Pain Management Timothy Hudson, MD, MHA, LAc, FAAPMR Penn State Hershey Medical Center

  2. No disclosures

  3. “Drugs never cure disease. They merely hush the voice of nature’s protest, and pull down the danger signals she erects along the pathway of transgression.” Daniel Kress, MD

  4. 40% of patients with SCI have chronic nerve pain (Felix 2014) • Much has been tried in the treatment of pain, not a lot is perceived as useful with patients. (Warms 2002) Chronic Pain in SCI

  5. Classification • Nociceptive • Neuropathic • Other Pain (Felix 2014, Cardenas 2009) Overview of SCI Pain

  6. Over the counter • CAM therapies • Therapy / Exercise • SCI Pain • Opioids • Chronic pain medications • Neuropathic Pain Medications

  7. 40.3% used at least one CAM technique for pain (Nayak 2001) • 31% used acupuncture with 78% satisfaction • 31% used homeopathy with 91% satisfaction (Pannek 2015) • Massage and heat tend to be the most used (NorbringBudh 2004) Use of CAM in SCI

  8. Spinal cord injury patients • 96% have ever used CAM • 96% would ever recommend CAM • 71% would use CAM in the future • Practitioners • 77% have ever used CAM • 73% have ever recommended CAM • 65% would recommend CAM CAM Use at Penn State Hershey

  9. Transcranial direct current stimulation seemed to be useful in the short term and mid term • No evidence for repetitive transcranial magnetic stimulation, cranial electrotherapy stimulation, acupuncture, TENS, and self-hypnosis (Boldt 2011) Cochrane Review 2011

  10. The Basics

  11. Obesity at BMI’s less than 30 “No illness which can be treated by the diet should be treated by any other means.” – Maimonides (1135-1204) Diet

  12. Exercise is medicine: It can help. • Shoulder pain is reduced with a regular exercise program (Nawoczenski2006) Exercise

  13. Acupuncture

  14. Earliest recorded medical procedure in China • Believed to have started ~100 B.C. • Some developed use in other regions • Korea • Japan • Europe • France Origins and Status

  15. Standard Risks • Insertion site pain, insertion site infection, trapped needle, broken needles, pneumothorax, spinal hematomas • 3 of 15 patients demonstrated BP changes that could be imminent AD (Averill 2000) Risk of Acupuncture

  16. Activation of various chemicals through • Peripheral • Spinal • Supraspinal mechanisms • Including • Opioids • Cytokines • Serotonin • Norephinephrine • N-methyl-D-aspartate (NMDA) GluN1 phosphorylation (Zhang 2014) Mechanisms of Acupuncture

  17. Rodent models suggests AP • Decreases microglial activation, PGE2 production, and inflammatory mediators (Choi 2012) • Down-regulates excessive expression of interferon-gamma to reduce allodynia (Chen 2015) • Jun-N-Terminal Kinase (JNK) inhibited in astrocytes (Lee 2013) Mechanisms in SCI for neuropathic pain

  18. Acupuncture and massage both showed benefit • Acupuncture was favored over time and sustained more patients. (Norrbrink 2011) Acupuncture versus Massage

  19. Some benefit seen examined by itself (Dyson-Hudson 2007) • Acupuncture and Trager show benefit individually in PU-WUSPI (Dyson-Hudson 2001) Acupuncture in SCI Shoulder Pain

  20. 40% showed improvement after treatments • 1/15 worsened pain (Norbrink 2011) • 46% showed improvement • 27% complained of worsening (Nayak 2001) Acupuncture in Chronic Pain

  21. Other Complimentary and Alternative Therapies

  22. 16% improvement in pain with manipulative therapies (Arienti 2011) Osteopathic Manipulative Therapy

  23. Incomplete lesion, used Clinical Biomechanics of Posture protocol (Haas 2005) Chiropractic Care

  24. Spinal stenosis symptoms relieved after manipulation with deformation present on imaging (Kukurin 2004) • No evidence of myelopathy with cervical manipulation and cord encroachment seen on imaging (Murphy 2006) Manipulative Medicine

  25. “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Hippocrates (460-377 B.C.)

  26. Pain can be provoked by movement imagery. (Gustin 2010) • Visual illusion used in 5 paraplegic patients. • 53mm at post-procedure • 43mm at 3 month (Moseley 2007) Visual Illusion

  27. Small comparison showed hypnosis improved pain scores up to 3 months after (Jensen 2009) • Case report effective 6 months following (Stoelb 2009) • In general self-hypnosis has been sustainable in 20% of people with disabilities (Jensen 2008) Hypnosis

  28. Does not seem to be helpful in neuropathic pain from SCI (Jensen 2009) Biofeedback

  29. Case reports on 12 and then 7 veterans with SCI (Wardell 2006; Wardell 2008) Healing Touch

  30. Overall does seem to be beneficial in central neuropathic pain (Wade 2003) • Ethically and legally limiting Cannibis

  31. Individual oils / Blends • Topical / Diffused • Types • Numbing: • Anti-inflammatory: • Heat sensation: • Central processing: • Neurotrasmission: • Relaxation: Aromatherapy / Essential Oils

  32. Discussion

  33. Assessing the patient’s willingness can help us to understand their perception (Haythornthwaite 2003) • Considerations: • Cost • Monitoring results • Increased frequency? • Goals for treatment of pain and medications Integration

  34. Barriers • With patients • With practitioners • Complimentary approaches • Acupuncture • Massage • Manual therapy • Hypnosis Summary

  35. Questions?

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