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    1. 1. 10 High Street A PrivatePracticePainClinic. 1980 - 1990 Core Group: S Strauss MBBS Dip. Acupuncture,Nanking School Traditional Chinese Medicine, Nanking, China. 1978. FAMAS. Licentiate. AAMM T McCarthy. MBBS FFARACS Dip. Acupuncture, Nanking School TCM, Nanking, China. 1982. FAMAS. Plus: Physiotherapists, Psychiatrist (Pt.1.), Masseuse. 10,000 Patients from 1980 - 1990, 60% referred.
    2. 2. 10HighStreet. ResearchAreas. Initial aim was to explore Acupuncture's place within Western Medical Practice: Its mechanisms and treatment results. Led to investigation into: TriggerPoints Sympathetic Involvement & Manipulation Pain Measurement Pain diagrams, VAS, McGill Pain Questionnaire etc Thermography, Algometry, Axon Flare. Electro-diagnosis/provocation (Neurotrace etc] Nerve & TriggerPoint Blocks - Local anaesthetic, Cryoprobe etc. Afferent Stimulation Techniques (PSS) Pain Epidemiology
    3. 3. 10 High Street: Treatment Surveys Survey Number % of Responders Follow Up Method 1 124 100% 6/52 Telephone 2 637 75% 6/12+ Mail 3 2083 55% 12/12+ Mail 4 365 35% 3-4 Years Mail
    4. 4. 10 High Street. Pain State Distribution & Age Breakdown of 1146 Patient’s Pain Syndromes. From survey 3. 398 58 393 61 297 56 240 52 239 58 184 58 0 100 200 300 400 Neck Back Shoulder Headache CBS Sciatica
    5. 5. 10 High Street. Pain Severity 0 5 10 15 20 25 30 1 2 3 4 5 97% Could be regarded as having severe pain No Pain From Survey 4. Brisbane University School of Medicine Unbearable Pain
    6. 6. Pain Severity 10 High Street Compared with General Community Pain Population 0 5 10 15 20 25 30 35 40 1 2 3 4 5 10 High St. General Community Pain Population % No Pain From Survey 4. Brisbane University School of Medicine The Prevalence of Pain Complaints in a General Population: An Australian Study Unendurable Pain
    7. 7. 10 High Street. Reason for Presentation Otherforms of treatment had not helped: 63% “I’d have tried anything if I thought it would help”: 61% From Survey 4. Brisbane University School of Medicine
    8. 8. 10 High Street Back Pain Patients’ Profiles. Analysis of 137 Back Pain Patients Pain Distribution 49 -Low Back Pain 25 -Sciatica 18 -Buttock Pain 12 -LBP +Buttock 15 -LBP + Sciatica 12 -Thoracic Pain 8 -Post-Laminectomy Pain From Survey 2. 478 Responders. Follow up 6 months, mail survey. 75% response.
    9. 9. 10 High Street 137 Back Pain Patients’ Profiles. 55% NSAI’s / Analgesics (currently using on presentation) 16% Epidurals, 36% Chiropractic, 24% Physiotherapy, From Survey 2. 478 Responders. Follow up 6 months, mail survey. 75% response. From Survey 2 Total number of health professionals consulted was 380. Average pain duration was 6.8 years. 72% c/o disturbed sleep. 8% Laminectomy/Fusion.
    10. 10. 10 High Street Back Pain Patient’s Profiles. 49 Low Back Pain Only 22 had their pain reproduced by pressure on muscle “Tender Points” around the thoraco-lumbar junction. ( 8 of the 22 had pelvic tilts.) 25 Sciatica Only 20 of the 25 had a “Tender Point” (EM- 35) in the Gluteal musculature, which when pressed on replicated all or some of their pain. From Survey 2.
    11. 11. Analysis of 21 consecutive unilateral back pain patients Average age 57 years Average VAS = 5 [ 0………X………10cms ] Average SMPQ Sensory 5.76 Average SMPQ Affective 1.66 From “A Comparison of Axonal flares Reactions, Pressure Algometry and Skin Temperatures to Subjective Measures of Pain” Strauss, Burns* and Sprague*. Unpublished work. Brisbane Medical School*. 12 females, 9 males
    12. 12. Analysis of 21 consecutive unilateral back pain patients Temperature measurements of tender points compared to contralateral anatomic site. The mean Skin Temperature was 0.23 0C higher on the affected side Higher in 15 cases, same 2 and lower in 4 cases. Standard error of difference 0.11, a t score of 2.11 giving a confidence level of >95%) From “A Comparison of Axonal Flares Reactions, Pressure Algometry and Skin Temperatures to Subjective Measures of Pain” Strauss, Burns* and Sprague*. Unpublished work. Brisbane Medical School*. Temperature was measured with an InvotechC600M Biotherm Infrared thermometer. Sensitivity 0.1 0 C
    13. 13. Analysis of 21 consecutive unilateral back pain patients Axon Flare measurements of tender points compared to contralateral anatomic site. In 20 of the 21 cases the flares, induced by the insertion of 30 gauge solid stainless steel needles into the “Tender Point” and the mirror site, were larger on the pain side. Mean difference of 51.4 mm2. Standard error of difference = 0.35, t = 2.01, confidence level > 90% From “A Comparison of Axonal Flares Reactions, Pressure Algometry and Skin Temperatures to Subjective Measures of Pain” Strauss, Burns* and Sprague*. Unpublished work. Brisbane Medical School*.
    14. 14. Analysis of 21 consecutive unilateral back pain patients The Mean Pressure Threshold Female Tender Points was 1.84 kg/cm2. (N>3.8) From “A Comparison of Axonal Flares Reactions, Pressure Algometry and Skin Temperatures to Subjective Measures of Pain” Strauss, Burns* and Sprague*. Unpublished work. Brisbane Medical School*. Male Tender Points was 2.56 kg/cm2 (N>5.6) Threshold for whole group Tender Points = 2.4 kg/cm2 . Pressure Threshold Meter by Pain Diagnostics and Thermography. Sensitivity 100gms.
    15. 15. 10 High Street Patients’ Profiles. • A picture emerges of desperate patients suffering moderate to severe pain forseveral years, who had tried multiple forms of therapy without gaining sustained relief. • The majority of these patients’ syndromes involved the musculoskeletal system. • Many of the chronic pain patients seen at 10 High Street had “tenderpoints” which when pressed on reproduced some orall of theirpain.
    16. 16. Myofascial Tender Points Very few had had their“TenderPoints” medically palpated priorto presentation. Many expressed surprise when theirpain syndrome was reproduced by palpation.
    17. 17. Myofascial Tender Points Mostly Missed, Why? • Almost all had never completed a Pain Diagram, McGill Questionnaire, VAS etc. • Many had not been undressed at previous assessments. • Many had accepted being told that their pain had no physical cause. • Contrary to prevailing paradigm.
    18. 18. IASP’s Journal “PAIN” “ Chronic Benign Intractable Pain Syndrome” (previously) defined as pain that has been present for more than six months without known peripheral nociceptive input is nearly always associated with Trigger Points. ( Back 96.7%, Neck 100%) Pain. Vol. 37 1989.
    19. 19. IASP’s Journal “PAIN” 283 consecutive admissions to a comprehensive pain center: The diagnosis made independently by a Neurosurgeon and a Physiatrist based on physical examination as described by Travell and Simons assigned a primary organic diagnosis of myofascial pain in 85% of the cases. Pain. Vol. 26:181-197 1986 Non Specific Low Back Pain in a General Practice setting is usually (80%) associated with Trigger Points. Pain. Vol.. 37. 1989.
    20. 20. TRIGGER POINTS The Emerging [Western] Paradigm Can be thought of as “Pain Amplifiers” ( T. McCarthy 1983 )
    21. 21. TRIGGER POINTS act as “Pain Amplifiers” where their activity – enhances nociceptor input, eg. Osteoarthritis, Facet Joint Syndromes etc. – augments sympathetic activity, eg. Reflex Sympathetic Dystrophy, Post Herpetic Neuralgia etc.
    22. 22. TRIGGER POINTS can be thought of as “Pain Generators” where trigger points are the actual tissue causing the pain state. ( T. McCarthy 1983) I.e. Myofascial Pain Syndromes.
    23. 23. Trigger Point Postulates • TrPs may be caused by sympathetically activated intrafusal contractions Spine. 1993 Oct 1;18(13) • The reduction in pain and TePs produced by a sympathetic blockade may be due to an improvement in microcirculation Pain, 33: 2, 1988 May, 161-7 • An endogenous opioid system may be the mediator for the decreased pain and improved physical findings following injection of myofascial trigger points with local anesthetic. Pain. 1988 Jan; 32(1): 15-20
    24. 24. TRIGGER POINTS Rx’s Directed @ the Trigger Points in the West • Spray and Stretch • Ischaemic pressure massage (Shiatsu) • Injection ( Local Anaesthetic, etc. ) • Dry Needling (Superficial, Deep, +/-multiple) • Acupuncture
    25. 25. Cold Bi Syndromes: According to the dictates of TraditionalAccording to the dictates of Traditional Chinese Medicine (TCM) Pain results fromChinese Medicine (TCM) Pain results from the blockage of Qi and blood.the blockage of Qi and blood. T.C.M’sT.C.M’s Cold Bi syndromesCold Bi syndromes include theinclude the majority of chronic musculoskeletal painmajority of chronic musculoskeletal pain states where “Tender Points” are associatedstates where “Tender Points” are associated with coldness of the painful area.with coldness of the painful area. The T.C.M. treatment paradigm is toThe T.C.M. treatment paradigm is to “Remove the obstruction thus allowing“Remove the obstruction thus allowing warming and nourishing of the tissues.”warming and nourishing of the tissues.”
    26. 26. Cold Bi Syndromes: Rx Rationale- a Western Translation ““Deactivate” the Trigger PointDeactivate” the Trigger Point thereby decrease thethereby decrease the local/regional, aberrantlylocal/regional, aberrantly enhanced, sympathetic outflowenhanced, sympathetic outflow activity associated with activeactivity associated with active trigger points.trigger points.
    27. 27. Acupuncture for Pain This “warming and nourishing of the tissues” is addressed by the use of the Near and Far Acupuncture Technique. The Near and Far method is the most commonly used Acupuncture technique for the resolution of chronic pain syndromes in the Peoples Republic of China.
    28. 28. The Near and Far Acupuncture Technique When the “Near and Far” technique is used to treat common pain states the treatment is aimed at resolving the tissue problem or reflex causing or maintaining the pain state.
    29. 29. The Near and Far Acupuncture Technique Two processes are dominant in this “rehabilitation” 1. The Ablation of Trigger Point Activity 2. The Restoration of Disordered Blood Flow As the provision of Analgesia in this context is a secondary consideration Electro-Acupuncture stimulation is rarely used in this context.
    30. 30. The Near and Far Acupuncture Technique Involves the use of both LOCAL and DISTAL Acupuncture points.
    31. 31. Local Points Where East Meets West • “Where there is a painful spot, there is an Acupuncture point” from the Neijing- The Yellow Emperor’s Classic of Internal Medicine- 500+ B.C. • When pressed on the Patient winces, or suddenly starts and exclaims “AAGH Is The POINT!” From Acupuncture a Comprehensive Text: Shanghai College of Traditional Chinese Medicine • Ah Shi - Oh Yes! as the patient’s pain complaint is reproduced by palpation. Nanking College of TCM
    32. 32. Myofascial Trigger Points Where East Meets West Examination Difficulty Diagnostic value Spot Tenderness + ++ Jump Sign + + Pain Recognition ++ +++ Palpable Band +++ ++++ Referred Pain +++ + Twitch Response ++++ ++++ Both Western and TCM West Only Professor David Simons -Journal of Musculoskeletal Pain
    33. 33. Local Points…. AhShi - Oh Yes Trigger Points The Western equivalent of T.C.M’s AhShi point is the “Trigger Point” > 70% of Local Acupuncture Points for Pain correspond to Trigger Points………....R. Melzack Pain 3 Vol.. 3. 1977
    34. 34. Distal Acupuncture Points • Are classical meridian Acupuncture points usually found below the elbow or knee. • They are used for the treatment of many autonomically based diseases. In the pain Rx context: Commonly used distal points are characteristically found in muscles often at the motor point. e.g. Li 4 - Hegu, Li 10 - Shousanli.
    35. 35. Distal Acupuncture Points 1. the sympathetic nervous system. 2. the various “Pain Gates” Can be used to manipulate
    36. 36. Acupuncture & Sympatholysis Sympathetic vasomotor changes induced by manual and electrical acupuncture of the Hoku point visualized by thermography. Author Ernst M; Lee MH Both manual and electrical acupuncture produced a generalized long-lasting warming effect, indicating reduced sympathetic activity (sympatholytic effect). In addition, electrical acupuncture induced a localized short-term cooling effect, indicating a transient segmental increase in sympathetic activity (sympathomimetic effect). Source Pain, 1985 Jan, 21:1, 25-33
    37. 37. Sympathetic vasomotor changes induced by manual and electrical acupuncture of the Hoku point visualized by thermography Hoku / Hegu Point - Li 4 Perhaps the most researched Acupuncture point. Motor point of Abductor Pollicis. Used clinically to provide analgesia, sympatholysis etc. Face Face Hands Feet
    38. 38. Acupuncture and Sympatholysis The Warming Effect of Acupuncture on Nose Tip Temperature on Cold Nosed ( < 34o C ) Patients c/o Headache and Anxiety Li11 + Li4, Bu 20 mins. Average Temperature increase = 2.26o C -4 -3 -2 -1 0 1 2 3 4 5 6 T 5 20 Mins 0 C E*
    39. 39. Acupuncture & Sympatholysis Somatic sympathetic vasomotor changes documented by medical thermographic imaging during acupuncture analgesia. Authors: Thomas D; Collins S; Strauss S Clin Rheumatol, 1992 Mar, 11:1, 55-9 This prospective study of 20 patients with neck and arm pain measured finger temperature, controlled by somatic sympathetic vasomotor activity before and after needle acupuncture. Responses were correlated with visual analogue scale (VAS) of pain severity. An association was found between pain relief and reduced sympathetic vasomotor activity.
    40. 40. The Near and Far Technique for Chronic Pain States: Nanking 1978. • The skin over the distal points is painlessly penetrated • The needle is ‘Twirled’ 90-1800 left - right as well as up and down until needle grasp or subjective Deqi is experienced. • This distal point subjective Deqi can be sensations of numbness, tingling, distension or dull pain. • The “amount” of deqi provided is titrated against the condition. • Where sympatholysis is required the needle is gently manipulated and left in situ for 20+ minutes. Distal Points Needle Technique
    41. 41. The Near and Far Technique for Chronic Pain States: Nanking 1978 • The needle is then twirled (900 left-right ) with downwards pressure until the trigger point is penetrated and “needle grasp” Objective - Deqi occurs. • At this stage the patient’s typical pain can/should be replicated. [Qi reaching the pain] -a type of Subjective Deqi or Acupuncture sensation. • The needle is left in situ for 20+ minutes. Local Points • A fine 30 - 32 Gauge needle is painlessly inserted through the skin over the active trigger point/points.
    42. 42. Results of Acupuncture Rx using the Near & Far Technique. Overview Survey 1. 100% referred, 100% follow up. Survey 3. NHMRC funded Survey 4. Brisbane Medical School Survey Number % of Responders Follow Up Acupuncture of Benefit? 1 124 100% 6/52 Yes 84% 2 637 75% 6/12+ Yes 88% 3 2083 55% 12/12+ Yes 87% 4 365 35% 3-4 Years Yes 85%
    43. 43. Surveys: Designed to elucidate the Patient’s Opinion of their response to Acupuncture Treatment. Following your Acupuncture Treatment • Is your Pain: More freq., same, less freq., greatly less freq., No pain / never • Is your Pain: More severe, same, less severe, very much less severe, no pain • Has your range of movement: improved, greatly improved, full, unchanged, not limited before • General Questions: Included Age, Drug Usage and Sleep Disturbance. • Was Acupuncture of benefit? • Same question format used for surveys 1, 2 & 3.
    44. 44. Survey 2. • Follow up by mail at 6 months + • Patient Number = 637 • Response rate 75%, Yielding 478 responders. • Total number of specifically treated complaints = 912 • Average number of treatments per patient = 7.8 • Pain duration varied with type / site of pain. • NB All private patients. (No Workers Compensation Involvement)
    45. 45. Survey 2. Overview of Results 0 10 20 30 40 50 60 70 80 Back Headache Anxiety C.B.S. Knee Sciatica Neck Helped Greatly Helped Greatly helped = Very much less - no pain (Severity and frequency), Greatly decreased - nil medication, improved - normal sleep,R.O.M. increased +++ NB Patient’s subjective opinion %
    46. 46. Survey 2. Low Back Pain 0 10 20 30 40 More Less V. Much Less No Pain Pain Freq. Pain Sev. 136 cases Acupuncture of Benefit ? Yes 119 ( 87.5% ) No 17 ( 12.5% ) Sleep Disturbance Improved - Back to normal 88%
    47. 47. Survey 2. Neck and Arm Pain • Neck and Arm Pain ( Cervico-brachial syndrome ) 72 cases • Average Number of treatments 7.4 • Acupuncture of Benefit? Yes 87% • Limitation of Movement- Improved 26%, Greatly Improved 71% • Frequency of pain- Less 18%, very much less - no pain 70% • Severity of pain- less 10%, none - very much less 77% • Sleep Improved 64%, Back to normal 19% • Greatly helped with less than 5 treatments pain duration 2.1 years. • Greatly helped with more than 5 treatments pain duration 5.4 years. • Pain duration Helped group 7.5 years Greatly helped GP. 4.3 years
    48. 48. Survey 4.Brisbane Medical School Follow up @ 3 - 4 Years • Duration of Improvement for those reporting pain relief. Less than 2 weeks....................................7.4% 2 weeks - 3 months...................................7.4% More than 3 months...,,......................... 16.7% Still better at time of survey.................68.5%
    49. 49. Survey 4.Brisbane Medical School Follow up @ 3 - 4 Years In what way had the Pain Improved: • It occurred less frequently....................9.2% • It was not as intense............................11.1% • It was less intense & occurred less Frequently.....................79.7%
    50. 50. From medline 1 of 3,300 A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Author Garvey TA; Marks MR; Wiesel SW Address Department of Orthopaedic Surgery, George Washington University Medical Center, Washington, D.C. Source Spine, 1989 Sep, 14:9, 962-4 Abstract The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had non-radiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication.