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

CHRONIC PAIN IN SCI

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)

OVERVIEW OF SCI PAIN

Classification Nociceptive

Neuropathic

Other Pain

(Felix 2014, Cardenas 2009)

Neuropathic Pain

Nociceptive PainOther Pain

SCI Pain

Over the

counter

Therapy /

Exercise

Chronic pain

medications

Neuropathic Pain

Medications

Opioids

CAM therapie

s

USE OF CAM IN SCI

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)

CAM USE AT PENN STATE HERSHEY

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

COCHRANE REVIEW 2011

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)

THE BASICS

DIET

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)

EXERCISE

Exercise is medicine: It can help.

Shoulder pain is reduced with a regular exercise program

(Nawoczenski 2006)

ACUPUNCTURE

ORIGINS AND STATUS

Earliest recorded medical procedure in China Believed to have started ~100 B.C.

Some developed use in other regions Korea

Japan

Europe France

RISK OF ACUPUNCTURE

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)

MECHANISMS 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 IN SCI FOR NEUROPATHIC PAIN

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)

ACUPUNCTURE VERSUS MASSAGE

Acupuncture and massage both showed benefit

Acupuncture was favored over time and sustained more patients.

(Norrbrink 2011)

ACUPUNCTURE IN SCI SHOULDER PAIN

Some benefit seen examined by itself

(Dyson-Hudson 2007)

Acupuncture and Trager show benefit individually in PU-WUSPI

(Dyson-Hudson 2001)

ACUPUNCTURE IN CHRONIC PAIN

40% showed improvement after treatments

1/15 worsened pain

(Norbrink 2011)

46% showed improvement

27% complained of worsening

(Nayak 2001)

OTHER COMPLIMENTARY AND ALTERNATIVE THERAPIES

OSTEOPATHIC MANIPULATIVE THERAPY

16% improvement in pain with manipulative therapies

(Arienti 2011)

CHIROPRACTIC CARE

Incomplete lesion, used Clinical Biomechanics of Posture protocol

(Haas 2005)

MANIPULATIVE MEDICINE

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)

“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.)

VISUAL ILLUSION

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)

HYPNOSIS

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)

BIOFEEDBACK

Does not seem to be helpful in neuropathic pain from SCI

(Jensen 2009)

HEALING TOUCH

Case reports on 12 and then 7 veterans with SCI

(Wardell 2006; Wardell 2008)

CANNIBIS

Overall does seem to be beneficial in central neuropathic pain

(Wade 2003)

Ethically and legally limiting

AROMATHERAPY / ESSENTIAL OILS

Individual oils / Blends

Topical / Diffused

Types Numbing:

Anti-inflammatory:

Heat sensation:

Central processing:

Neurotrasmission:

Relaxation:

DISCUSSION

INTEGRATION

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

Neuropathic Pain

Nociceptive PainOther Pain

SCI Pain

Over the

counter

Therapy /

Exercise

Chronic pain

medications

Neuropathic Pain

Medications

Opioids

CAM therapie

s

SUMMARY

Barriers With patients

With practitioners

Complimentary approaches Acupuncture

Massage

Manual therapy

Hypnosis

QUESTIONS?

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