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SEEKING THE DRAGON PEARL… MUSCULOSKELETAL PAIN? WRONG TARGET. Milton Cohen FPMANZCA ASM, Hong Kong , May 2011. The “implementation gap” How do we use the information we have? We don’t use the evidence we have. Dr Steve Yentis , Ellis Gillespie Lecture, 14 May 2011. Low back pain

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seeking the dragon pearl musculoskeletal pain wrong target

SEEKING THE DRAGON PEARL…MUSCULOSKELETAL PAIN?WRONG TARGET

Milton Cohen

FPMANZCA ASM, Hong Kong, May 2011

slide2

The “implementation gap”

How do we use the information we have?

We don’t use the evidence we have.

Dr Steve Yentis, Ellis Gillespie Lecture, 14 May 2011

pseudodiagnoses
Low back pain

Musculoskeletal pain

Neuropathic pain

“Myofascial” pain

“Fibromyalgia”

Facet joint “arthritis”

Internal disc disruption

“Sciatica”

“Neuralgia”

PSEUDODIAGNOSES
the dominant paradigm
Biomedical focus

Anatomical determinism

Confused and confusing nomenclature

The dominant paradigm…
that has reached its use by date
Biomedical focus >> “Biopsychosocial”

Anatomical determinism >> Functional appeciation

Confused nomenclature >> Rational understanding

…that has reached its use-by date
slide6

ENVIRONMENT

PERSON

BRAIN

AND

NERVOUS

SYSTEM

BODY

slide7

ENVIRONMENT

-social

PERSON

-psycho-

BRAIN

AND

NERVOUS

SYSTEM

Bio-

BODY

three arguments
THREE ARGUMENTS
  • From neurobiology
  • From therapeutics
  • From terminology
central sensitisation
CENTRAL SENSITISATION
  • “…once triggered remained autonomous for some time, or only required a very low level of nociceptor input to maintain it.”
  • “Pain…might not necessarily reflect the presence of a peripheral noxious stimulus.”
  • “Pain could…become the equivalent of an illusory perception…”

Woolf C. Pain 2011;152:S2-S15

clinical implications of central sensitisation of nociception
Diagnostic criteria

Avoid chasing nociception in region of pain

Nociception vs perception

Words!

What are we doing with drugs?

CLINICAL IMPLICATIONS OF CENTRAL SENSITISATION OF NOCICEPTION
anterior cingulate cortical acc activation
Anterior cingulate cortical (ACC) activation
  • Thermal injury

(Koyama et al 2003)

  • Rectal distention

(Wilder-Smith et al 2004)

  • Hearing pain words

(Osaka et al 2004)

  • Viewing facial expressions of pain

(Botvinick et al 2005)

  • Social exclusion

(Eisenberger et al 2003)

slide13

A model regarding brain circuitry involved in the transition

from acute to chronic pain. Apkarian et al. Pain 2011:152:S49-S64

slide14

BRAIN

AND

NERVOUS

SYSTEM

HYPERVIGILANCE

HYPERALGESIA

BODY

slide15

BRAIN

AND

NERVOUS

SYSTEM

CONTEXTUAL EFFECT

HYPERVIGILANCE

HYPERALGESIA

MAINTAINING

SENSITISATION

BODY

three arguments1
THREE ARGUMENTS
  • From neurobiology
  • From therapeutics
  • From terminology
acupuncture
A review of reviews

Ernst et al. Pain 2011;152:755-764

“It is becoming increasingly clear that the surrounding ritual, the beliefs of patient and practitioner and the nonspecific effects of treatment are likely responsible for any reported benefits.”

Hall, H. Commentary. Pain 2011;152:711-712

ACUPUNCTURE
myofascial pain syndrome is it credible
Variability of criteria used to diagnose myofascial trigger point pain syndrome - Evidence from a review of the literature.

Tough EA et al, Clin J Pain 2007;23:278-286

Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature.

Lucas N et al. Clin J Pain 2009; 25: 80-9.

MYOFASCIAL PAIN (SYNDROME)Is it credible?
slide19
Systematic review of needling as a treatment for myofascial trigger point pain

Cummings TM, White AR. Arch Phys Med Rehabil 2001;82:986-92

The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature.

Rickards LD. Int J Osteopath Med 2006; 9:120-136

“Know that the best evidence for the treatment of myofascial pain is extremely limited.”IASP Curriculum
more studies are needed
Shoulder pain

“There is some evidence from methodologically weak trials to indicate that some physiotherapy interventions are effective for some specific shoulder disorders.”

(Green et al. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004258)

Low back pain

“In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural corticosteroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical interventional therapies (intradiscal electrothermal therapy, radiofrequency denervation), spinal manipulative therapy, surgery, traction, and transcutaneous electrical nerve stimulation(TENS).” (Chou R. Clinical Evidence [Clin Evid (Online)] 2010 Oct 08)

“More studies are needed…”
more studies may not be the answer
“…the positive studies are false positives…”

“No matter how many studies showed negative results, they would not persuade true believers to give up their beliefs.”

Hall, H. Commentary. Pain 2011;152:711-712.

“More studies [may not be] the answer…”

How do we use the information we have?

We don’t use the evidence we have.

conceptual shift
Chronic “musculoskeletal” pain is attributable to

altered central nociceptive and/or

perceptual function

rather than reflecting

active peripheral pathology

CONCEPTUAL SHIFT
three arguments2
THREE ARGUMENTS
  • From neurobiology
  • From therapeutics
  • From terminology 
clinical nomenclature
“Pain” unacceptable as a diagnosis

Biomedical matrix dominant

anatomical determinism

pseudo-mechanistic dichotomy

Where are the “-psycho-” and “-social” components

CLINICAL NOMENCLATURE
slide25

A FALSE DICHOTOMY

“NOCICEPTIVE”

“NEUROPATHIC”

slide26

REPLACING THE DICHOTOMY

“NOCICEPTIVE”

“NOCIPLASTIC”

“NEUROPATHIC”

a matrix for the bio contribution
[type] [site of pain]

OR

[hypothesis of pathogenesis] [site of clinical pain]

A MATRIX FOR THE “BIO-” CONTRIBUTION
knee pain
[knee] [arthritis]

[inflammatory] [knee impairment]

KNEE PAIN

knee “osteoarthritis”

= symptomatic osteoarthrosis of the knee

= biomechanical impairment of the knee

on the [sufficient but not necessary] basis of osteoathrosis

[biomechanical] [knee impairment]

spinal referred pain
(chronic) [low back] [pain]

?nociceptive ?neuropathic

[nociplastic] [lumbar spine impairment]

leg pain in segmental distribution + signs of radiculopathy

lumbar radiculopathy

[radiculopathic] [leg impairment]

leg pain in non-segmental distribution with no signs of neurological deficit

somatic referred pain in leg

[nociplastic] [leg impairment]

SPINAL ± REFERRED PAIN
crps and fibromyalgia
Complex regional “pain syndrome” of arm

? inflammatory ?neuropathic

[nociplastic] [upper limb impairment]

“Fibromyalgia” or “myofascial pain” (“syndrome”)

? nociceptive neuropathic

[diffuse] or [local] [nociplastic] [impairment]

“CRPS” and “FIBROMYALGIA”
three arguments3
THREE ARGUMENTS
  • From neurobiology
  • From therapeutics
  • From terminology 
the dragon pearl for musculoskeletal pain
“Target” is CNS and its person

Transcending face validity

of biomedical approach (“old paradigm”)

New nomenclature required

The “dragon pearl” for “musculoskeletal” pain ?