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
PSEUDODIAGNOSES
• Low back pain
• Musculoskeletal pain
• Neuropathic pain
• “Myofascial” pain
• “Fibromyalgia”
• Facet joint “arthritis”
• Internal disc disruption
• “Sciatica”
• “Neuralgia”
The dominant paradigm…
• Biomedical focus
• Anatomical determinism
• Confused and confusing nomenclature
…that has reached its use-by date
• Biomedical focus
>> “Biopsychosocial”
• Anatomical determinism >> Functional appeciation
• Confused nomenclature >> Rational understanding
ENVIRONMENT
PERSON
BRAIN
AND
NERVOUS
SYSTEM
BODY
ENVIRONMENT
PERSON
BRAIN
AND
NERVOUS
SYSTEM
BODY
-social
-psycho-
Bio-
THREE ARGUMENTS
• From neurobiology
• From therapeutics
• From terminology
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
Yunus MB. Semin Arth Rheum 2007; 36:339-356
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?
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)
A model regarding brain circuitry involved in the transition
from acute to chronic pain. Apkarian et al. Pain 2011:152:S49-S64
HYPERVIGILANCE
BRAIN
AND
NERVOUS
SYSTEM
HYPERALGESIA
BODY
HYPERVIGILANCE
CONTEXTUAL
EFFECT
BRAIN
AND
NERVOUS
SYSTEM
HYPERALGESIA
BODY
MAINTAINING
SENSITISATION
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
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.
“Know that the best evidence for the treatment
of myofascial pain is extremely limited.”
IASP Curriculum
•
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
“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 [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.
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
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
A FALSE DICHOTOMY
“NOCICEPTIVE”
“NEUROPATHIC”
REPLACING THE DICHOTOMY
“NOCICEPTIVE”
“NOCIPLASTIC”
“NEUROPATHIC”
A MATRIX FOR THE “BIO-” CONTRIBUTION
[type] [site of pain]
OR
[hypothesis of pathogenesis] [site of clinical pain]
KNEE PAIN
[knee] [arthritis]
[inflammatory] [knee impairment]
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]
“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]
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