US FDA has approved a novel neurostimulation device with motion sensor technology for the treatment of chronic back and/or leg pain.

The device is called AdaptiveStim With RestoreSensor and built by Medtronic. It uses an implantable pacemaker-like device to interrupt pain signals, transforming them into a tingling sensation instead of pain.

The manufacturer says in a press release

Neurostimulation systems consist of an implantable medical device similar to a pacemaker to interrupt pain signals from reaching the brain.

The treatment has become a mainstay of chronic pain management; however, a change in body position (e.g., sitting up or lying down) can result in an increase or decrease in the intensity of stimulation as a patient’s spinal cord moves closer or further away from the stimulation site.

As a result, patients may need to make frequent manual adjustments to their stimulation levels as they move, using a handheld patient programmer, that the device automatically tailors the level of stimulation to the needs of people with chronic back and/or leg pain by adjusting stimulation to accommodate changes in body position.

AdaptiveStim with RestoreSensor reduces the need for manual programming changes by automatically adapting stimulation levels to the needs of people with chronic back and/or leg pain by recognizing and remembering the correlation between a change in body position and the level of stimulation needed.

It also records and stores the frequency of posture changes, providing objective feedback to clinicians to help them understand how a patient’s individual stimulation requirements are changing over time.

AdaptiveStim with RestoreSensor is approved by the FDA for use in MRI head scan.

In a clinical trial, 64 out of 74 patients included in an intent-to-treat analysis reported more pain relief with no loss of convenience, or improving convenience with no loss of pain relief.

In addition, more than 90% of participants indicated that they would keep the device turned on all or most of the time, and 80.3% reported functional improvements.

Use of the device was not associated with an increase in adverse events.

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Psychological Distress

Depression and anxiety can make pain seem worse.

Chronic pain can lead to a cycle of increasing depression and reduced physical activity. The reduced physical activity can lead to reduction in pain in the short term  causes increase in pain in the long term.

Misinterpretation/Over-interpretation of Pain Signals.

This pain is referred to as catastrophizing (the tendency to think the worst when one feels pain). This pain gets  worsened by reliance on patient support groups.

Gate Control Theory of the pain states that, when we are worried about a particular body part, the brain can actually signal to the spinal cord that it should be more apt to interpret nerve impulses from that body part as pain and pass them on to the brain.

In patients with chronic arm pain, the brain may even learn to automatically trigger pain whenever the limb is moved, as a defense mechanism to prevent further movement.

Health Anxiety

A sense that something is seriously wrong that does not lessen with normal test results and reassurance from health professionals. Patient presents with a strong intuition that their pain indicates existing and ongoing tissue damage.

One explanation is that they have a strong “pain alarm”—pain tends to be accepted as a sign of danger.

Some physicians and medical researchers believe that stress is the main cause, rather than a contributing facto

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The use of topical NSAIDs vary in different countries.In theory they have potential to provide pain relief without associated systemic adverse events.”

Recent report published on June 16,2010 has evaluated the evidence from randomized, double-blind, controlled trials of the efficacy and safety of topically applied NSAIDs for relief of acute pain.

It was found that all topical NSAIDs like diclofenac, ibuprofen, ketoprofen, and piroxicam were effective but indomethacin and benzydamine were not significantly more effective than placebo.

There were very few systemic adverse events or adverse events causing study withdrawals, and local skin reactions were usually mild, self-limited, and not different from those seen with placebo.

The study concluded

Topical NSAIDs can provide good levels of pain relief, without the systemic adverse events associated with oral NSAIDs, when used to treat acute musculoskeletal conditions in adults.

Author’s Note

Topical NSAIDs have always been controversial for use in musculoskeletal pains. Recent study consisting of systematic review has provided good evidence for rationale of use of topical NSAIDs in acute musculoskeletal problems.

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A lot of research has been done to determine the factors responsible for persistent pain following injury.

Earlier studies suggested that factors other than the physical injury are important in the development of persistent pain.

A recent study involving 168 participants between 18-64 years evaluated the  association between a range of biopsychosocial factors and the presence of persistent pain, pain severity, and pain interfering with normal work activities in a cohort of patients after of non-life-threatening orthopaedic injuries.

The study found that high initial pain, external attributions of responsibility for the injury, and psychological distress are factors that strongly predict persistent pain, pain-related work disability, and pain severity.

The study has been recently published in Journal of Pain.

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A mirror box is a box with two mirrors in the center (one facing each way), invented  and uses the principle of visual feedback to alleviate limb pain.

In this, the patient places the good limb into one side, and the stump into the other. The patient then looks into the mirror on the side with good limb and sees the reflection of good limb in place of stump.  Because the subject is seeing the reflected image of the good hand moving, it appears as if the phantom limb is also moving.

Through the use of this artificial visual feedback it becomes possible for the patient to “move” the phantom limb, and to unclench it from potentially painful positions.

Studies have found that use of the mirror box can eliminate the remapping associated with phantom limb pains.

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This was conceptualized by neurologist Dr Robert J. Schwartzman

The basis for using it to treat CRPS may reside in its strong ability to block  N-methyl D-aspartate (NMDA) receptors.There is sufficient evidence to suggest that a intense or prolonged painful stimulus causes an extraordinary release of glutamate from peripheral nerve fibers that carry pain information.

This glutamate stimulates NMDA receptors on second-order neurons that produce the phenomena central sensitization.

Thus it seems reasonable that by blocking NMDA receptors, one might also be able to block cellular mechanisms supporting windup and central sensitization.

Ketamine is a potent NMDA-blocking drug  and  prolonged infusion of ketamine appears to maintain a level of ketamine in the central nervous system long enough to reverse the effects of the sensitization process and associated pain.

The ketamine therapy can be done by a low dose ketamine infusion of between 10–90 mg per hour over several days.

The second treatment modality consists of putting the patient into a medically-induced coma, then administering an extremely high dosage of ketamine; typically between 600–900 mg.

However, the ketamine thearpy does not have final word on it yet. There are no credible reports in the peer-reviewed literature of such immediate and long lasting effects from this treatment.

Proper clinical trials are required before we know the effects and the risks of this procedure.

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Physiotherapy as the word itself indicates is a therapy wherein pain relief and mobilization is provided by physical means like heat and cold, traction, manipulation and electrical stimulation. This therapy is an useful adjunct to conventional methods to provide pain relief and restoration of normal function.

It is a multi-disciplinary approach to pain control that is customized to each patient’s individual needs.  Pian management programs are required for patients with chronic unrelenting pains. Following conditions may warrant initiation of pain management  program in a patient.

• Back pain or Sciatica
• Neck  pain
• Failed back syndrome
• Reflex Sympathetic Dystrophy
• Myofascial pain
• Fibromyalgia
• Facial pain
• Neuropathic pain
• Headaches
• Cancer pain
• Pain of Shingles (Herpes Zoster/ Post Herpetic Neuralgia)
• Chronic Pelvic pain
• Central pain syndromes (from spinal cord/injury, stroke, multiple sclerosis, etc.)
• Phantom Limb pain

While planning the patient for the program, a detailed history of the nature of the pain and medical history of patient should be taken and treatment individualized as required. The measures commonly involved (Not a complete list though) as part of pain management programme are as follows:

1. Electrotherapy

• Cold therapy
• Heat therapy
• Ultrasound
• Transcutaneous electrical nerve stimulation

2. Manipulative therapy

• Soft tissue techniques (massage)
• Passive mobilization of joints
• Passive stretching of soft tissues
• Autostretching of soft tissues
• Orthoses/ supports

3. Hydrotherapy

4.  Nerve blocks or radiofrequency ablation

5.  Biofeedback

6. Relaxation and stress management

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Type I

It was formerly known as reflex sympathetic dystrophy, Sudeck’s atrophy, reflex neurovascular dystrophy or algoneurodystrophy. This type does not have a demonstrable nerve lesions.

Type II

It was formerly known as causalgia and is associated with obvious nerve damage.

Exact cause of this syndrome is not known. Injury and surgery are known predisposing factors but cases  can occur without these factors too. wrist fractures and are quite commonly associated with CRPS.
Contents

Clinical Presentation

The symptoms of complex regional pain syndrome are usually spread beyond the original area of injury.It may involve the entire limb and sometimes other limb too.

The most common complaint is that of overall are burning and shooting pain. The pain is continuous and may be aggravated by emotional stress.

Examination may reveal

• Local swelling
• Hyperhydrosis or increased sweating
• Raised skin temperature
• Skin may look reddish due to blood profusion and can be smooth and moist to touch
• Joint tenderness and stiffness
• Skin and nail atrophy

The symptoms of complex regional pain syndrome vary in severity and duration.

Previously, it was thought that CRPS has three stages but the experience has taught us that the stages are neither sequential nor time limited and not every patient goes through these stages.  Therefore they are considered more like variants.

• Type one is characterized by severe, burning pain at the site of the injury. Muscle spasm, joint stiffness, restricted mobility, rapid hair and nail growth, and vasospasm (a constriction of the blood vessels) that affects color and temperature of the skin can also occur.

• Type two is characterized by more intense pain. Swelling spreads, hair growth diminishes, nails become cracked, brittle, grooved, and spotty, osteoporosis becomes severe and diffuse, joints thicken, and muscles atrophy.

• Type three is characterized by irreversible changes in the skin and bones, while the pain becomes unyielding and may involve the entire limb. There is marked muscle atrophy, severely limited mobility of the affected area, and flexor tendon contractions (contractions of the muscles and tendons that flex the joints). Occasionally the limb is displaced from its normal position, and marked bone softening and thinning is more dispersed.

Diagnosis

CRPS types I and II share the common diagnostic criteria shown below.

• There is a history of edema, skin blood flow abnormality, or abnormal sweating in the region of the pain since the inciting event.
• No other conditions can account for the degree of pain and dysfunction.

The two types differ only in the nature of the inciting event. Type I CRPS develops following an initiating noxious event that may or may not have been traumatic, while type II CRPS develops after a nerve injury.

No specific test is available for CRPS, which is diagnosed primarily through observation of the symptoms. Thermography, sweat testing, x-rays,  Nerve electrodiagnostics, and sympathetic blocks can be used to build up a picture of the disorder.

Diagnostic criteria for complex regional pain syndrome I

• The presence of an initiating noxious event or a cause of immobilization
• Continuing pain, allodynia [Perception of pain from a nonpainful stimulus], or hyperalgesia [Pain disproportionate to the stimulus]
• Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the area of pain
• The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

CRPS II (causalgia) is diagnosed as follows:

• The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve

• Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain
• The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

CRPS  needs to be differentiated from shoulder-hand syndrome,  erythromelalgia and myasthenia gravis.

Treatment

Multimodal treatment is used in treatment of CRPS. A combination of medicine and physical therapies is used.

A variety of drugs are used to treat CRPS which include antidepressants, anti-inflammatory drugs,  vasodilators, GABA analogs such gabapentin and pregabalin, and alpha- or beta-blockers, and  opoid analgesics.

Physical and occupational therapy aim at  desensitizing the affected body part, restoring motion, and improving function.

Physical therapy works best for most patient. Therapy is directed at facilitating the patient to engage in physical therapy, movement and stimulation of the affected areas.

Recent studies have indicated success with Mirror Therapy. In this the affected limd is placed with in a mirror box and  the unaffected limb is reflected in such a way as to make the patient think they are looking at the affected limb. Movement of this reflected normal limb is then performed such that it looks to the patient as though they are performing movement with the affected limb. Following this movement of the normal limb, when the affected limb is moved, levels of pain are reduced and over a longer period significant changes between controls and intervention groups have been shown.

Injection of a local anesthetic and  topical lidocaine patches have been shown to be effective too.

Surgical, chemical, or radiofrequency sympathectomy [interruption of the affected portion of the sympathetic nervous system] can be used as a last resort in patients with impending tissue loss, edema, recurrent infection, or ischemic necrosis but evidence of effectiveness is not enough.

Biofeedback, psychotherapy, relaxation techniques and hypnosis  are adjunctive treatments which have been used in treatment to improve coping.

Ketamine Therapy have also been claimed to control and remit CRPS but needs more evidence.

Prognosis

If the treatment is begun early good progress can be made. The prognosis is not always good in delayed cases. In extreme cases amputation might be advised to get rid of annoying and non functional limb.

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Pressing the  trigger point may cause local tenderness, referred pain, or local twitch response.

The trigger points frequently cause pain that frequently radiates from these points of local tenderness to broader areas, sometimes quite faraway from these points. In spite of being accepted them as a different entity, enough diagnostic criteria and cause of there origin is not known

The term “trigger point” was coined in 1942 by Dr. Janet Travell.

A typical trigger point is said to have following characteristics

• Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
• The painful point can be felt as a tumor or band in the muscle, and a twitch response/tenderness/referred pain can be elicited on stimulation of the trigger point.
• Palpation of the trigger point reproduces the patient’s complaint of pain

Not all trigger points may have these classical features though.

Pathophysiology

Exact mechanism is unknown.

The most recent proposed mechanism says  that trigger points are muscle spindles, made over-active by adrenalin stimulation. These very short muscle fibers (< 1 cm in length) called intrafusal muscle fibers  are activated by adrenalin via the sympathetic nervous system.

An event of muscular overload causes a prolonged release of calcium from the sarcoplasmic reticulum (storage unit for the muscle cell) which results in a sticking  cells leading  to a contracture with compression of capillaries and results in an increased local energy demand and local ischemia (loss of blood circulation) to the area. This energy crisis causes the release of chemicals that augment pain.

Types

Trigger points may be of following types

Active & Latent

An active trigger point is one that actively refers pain either locally or to another location

A latent trigger point is one that exists, but does not yet refer pain actively. It may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point.

Key & Satellites

A key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway, or creates it.

A satellite trigger point is one which is activated by a key trigger point.

Successfully treating the key trigger point often will resolve the satellite and return it from being active to latent, or completely treating it too.

Primary & Secondary.

A trigger point in many cases will biomechanically activate a secondary trigger point in another structure. The original trigger point is called primary trigger point.

Treating the primary trigger point does not treat the secondary trigger point.

What Activates A Trigger Point?

• Acute or chronic muscle overload
• Activation by other trigger points
• Psychological distress
• Direct trauma to the region
• Rradiculopathy ( Pain due to compression /trritation of nerve root
• Smoking

Where Can Trigger points Appear?

• Muscles
• Tendons
• Ligaments
• Skin
• Joint capsule
• Scar tissue.

Diagnosis

Trigger points are diagnosed by clinical history and examination that includes manual palpation. Pain patterns and a taut band or hard nodule guide to the diagnosis. A twitch response can be felt in the muscle by running finger perpendicular to the muscle’s direction. Pressing on an affected muscle can often refer pain.

Treatment

Treatment of trigger points involves  manual massage,  mechanical vibration, pulsed ultrasound, electrostimulation, ischemic compression, local anaesthetics/steroid injection, low Level Laser Therapy and stretching techniques that invoke reciprocal inhibition within the musculoskeletal system.

After trigger points have been deactivated, muscle and fascial stretching should be done by active/passive means stretching to be effective to prevent redevelopment.

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It is most useful in acute musculoskeletal pain associated with sports injures or trauma.

Whenever cold stimulus (ice pack) is applied to skin, it melts and removes heat from tissues. This leads to vasoconstriction (The blood vesseles get constricted, their lumen and their capacity to carry blood increases),  reduction of nerve conductivity (As a result the nerve becomes less sensitive), reduction of muscle spasm and spasticity. Once the cold stimulus is taken off, the temperature of the area reaches normal level by vasodilatation.

This vasodilatation bring fresh blood which flushes inflammatory mediations. Again reapplication of cold stimulus repeats same event.

Alternate vasoconstriction and vasodilatation helps in tissues healing and pain relief.

Ice can be applied in towels as a pack or by immersion in a bath. Damp towels dipped in an ice and water mixture or containing crushed or flaked ice, can be wrapped round painful and swollen joints. The towels are changed every few minutes.

Ice Massage

In ice massage, an ice cube is wrapped in a towel at one end and the free end is massaged over the skin. This can act as counterirritant if applied for 5 to 7 minute to relieve pain and muscle spasm.

Ice therapy can alleviate pain frequently and onset of pain can be delayed by early application of therapy. This will reduce bleeding and oedema by causing vasoconstriction.

One should be careful while applying ice therapy for extremities like digits and toes for the risk of ischaemia or decreased supply of the oxygen to the tissues

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