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
“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

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

Classification

Nociceptive

Neuropathic

Other Pain
(Felix 2014, Cardenas 2009)
OVERVIEW OF SCI PAIN
Neuropathic
Pain
Other Pain
Nociceptive
Pain
Over
the
counter
Therapy
/
Exercise
CAM
therapies
SCI
Pain
Chronic
pain
medications
Opioids
Neuropathic
Pain
Medications

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
(Norbring Budh 2004)
USE OF CAM IN SCI


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

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
THE BASICS

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

Exercise is medicine: It can help.

Shoulder pain is reduced with a regular exercise
program
(Nawoczenski 2006)
EXERCISE
ACUPUNCTURE

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

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


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

Rodent models suggests AP

Decreases microglial activation, PGE2 production,
and inflammatory mediators
(Choi 2012)

Down-regulates excessive expression of interferongamma to reduce allodynia
(Chen 2015)

Jun-N-Terminal Kinase (JNK) inhibited in astrocytes
(Lee 2013)
MECHANISMS IN SCI FOR
NEUROPATHIC PAIN

Acupuncture and massage both showed benefit

Acupuncture was favored over time and
sustained more patients.
(Norrbrink 2011)
ACUPUNCTURE VERSUS
MASSAGE

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

40% showed improvement after treatments

1/15 worsened pain
(Norbrink 2011)

46% showed improvement

27% complained of worsening
(Nayak 2001)
ACUPUNCTURE IN CHRONIC
PAIN
OTHER COMPLIMENTARY AND
ALTERNATIVE THERAPIES

16% improvement in pain with manipulative
therapies
(Arienti 2011)
OSTEOPATHIC MANIPULATIVE
THERAPY

Incomplete lesion, used Clinical Biomechanics of
Posture protocol
(Haas 2005)
CHIROPRACTIC CARE

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
“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.)

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

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

Does not seem to be helpful in neuropathic pain
from SCI
(Jensen 2009)
BIOFEEDBACK

Case reports on 12 and then 7 veterans with SCI
(Wardell 2006; Wardell 2008)
HEALING TOUCH

Overall does seem to be beneficial in central
neuropathic pain
(Wade 2003)

Ethically and legally limiting
CANNIBIS

Individual oils / Blends

Topical / Diffused

Types

Numbing:

Anti-inflammatory:

Heat sensation:

Central processing:

Neurotrasmission:

Relaxation:
AROMATHERAPY / ESSENTIAL
OILS
DISCUSSION

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
Neuropathic
Pain
Other Pain
Nociceptive
Pain
Over
the
counter
Therapy
/
Exercise
CAM
therapies
SCI
Pain
Chronic
pain
medications
Opioids
Neuropathic
Pain
Medications


Barriers

With patients

With practitioners
Complimentary approaches

Acupuncture

Massage

Manual therapy

Hypnosis
SUMMARY
QUESTIONS?

Pannek J, Pannek-Rademacher S, Wöllner J. Use of complementary and alternative medicine in persons with spinal cord injury in Switzerland:
a survey study. Spinal Cord. 2015 Jul;53(7):569-72. doi: 10.1038/sc.2015.21. Epub 2015 Feb 24. PubMed PMID: 25708665.

Choi DC, Lee JY, Lim EJ, Baik HH, Oh TH, Yune TY. Inhibition of ROS-induced p38MAPK and ERK activation in microglia by acupuncture relieves
neuropathic pain after spinal cord injury in rats. Exp Neurol. 2012 Aug;236(2):268-82. doi: 10.1016/j.expneurol.2012.05.014. Epub 2012 May 23.
PubMed PMID: 22634758.

Norrbrink C, Lundeberg T. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study.
Acupunct Med. 2011 Jun;29(2):108-15. doi: 10.1136/aim.2010.003269. Epub 2011 Apr 6. PubMed PMID: 21474490.

Dyson-Hudson TA, Kadar P, LaFountaine M, Emmons R, Kirshblum SC, Tulsky D, Komaroff E. Acupuncture for chronic shoulder pain in persons
with spinal cord injury: a small-scale clinical trial. Arch Phys Med Rehabil. 2007 Oct;88(10):1276-83. PubMed PMID: 17908569.

Nayak S, Shiflett SC, Schoenberger NE, Agostinelli S, Kirshblum S, Averill A, Cotter AC. Is acupuncture effective in treating chronic pain after
spinal cord injury? Arch Phys Med Rehabil. 2001 Nov;82(11):1578-86. PubMed PMID: 11689979.

Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE, Druin EL. Acupuncture and Trager psychophysical integration in the treatment of
wheelchair user's shoulder pain in individuals with spinal cord injury. Arch Phys Med Rehabil. 2001 Aug;82(8):1038-46. PubMed PMID: 11494182

Boldt I, Eriks-Hoogland I, Brinkhof MW, de Bie R, Joggi D, von Elm E. Non-pharmacological interventions for chronic pain in people with spinal
cord injury. Cochrane Database Syst Rev. 2014 Nov 28;11:CD009177. doi: 10.1002/14651858.CD009177.pub2. Review. PubMed PMID: 25432061

Felix ER. Chronic neuropathic pain in SCI: evaluation and treatment. Phys Med Rehabil Clin N Am. 2014 Aug;25(3):545-71, viii. doi:
10.1016/j.pmr.2014.04.007. Review. PubMed PMID: 25064788.

Lee JY, Choi DC, Oh TH, Yune TY. Analgesic effect of acupuncture is mediated via inhibition of JNK activation in astrocytes after spinal cord
injury. PLoS One. 2013 Sep 9;8(9):e73948. doi: 10.1371/journal.pone.0073948. eCollection 2013. PubMed PMID: 24040124; PubMed Central
PMCID: PMC3767587.

Averill A, Cotter AC, Nayak S, Matheis RJ, Shiflett SC. Blood pressure response to acupuncture in a population at risk for autonomic
dysreflexia. Arch Phys Med Rehabil. 2000 Nov;81(11):1494-7. PubMed PMID: 11083354.

Nayak S, Matheis RJ, Agostinelli S, Shifleft SC. The use of complementary and alternative therapies for chronic pain following spinal cord injury:
a pilot survey. J Spinal Cord Med. 2001 Spring;24(1):54-62. PubMed PMID: 11587436.

Haas JW, Harrison DE, Harrison DD, Bymers B. Conservative treatment of a patient with syringomyelia using chiropractic biophysics protocols. J
Manipulative Physiol Ther. 2005 Jul-Aug;28(6):452. PubMed PMID: 16096046.

Norrbrink Budh C, Lundeberg T. Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective.
Complement Ther Med. 2004 Dec;12(4):189-97. PubMed PMID: 15649832.

Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of cervical spinal cord compression: a case series. J Manipulative Physiol
Ther. 2006 Mar-Apr;29(3):236-44. PubMed PMID: 16584950.

Kukurin GW. The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation:
a case report with long-term follow-up. J Manipulative Physiol Ther. 2004 Jun;27(5):e7. PubMed PMID: 15195045.
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