Cold Water Immersion or Contrast Hot/Cold Water Immersion Therapy – Does This Reduce Pain?

Dear Pain Matters blog readers,

Summer is fast approaching ‘Down Under’ (where I live, in Sydney, Australia).  As such, I am swimming and snorkelling almost daily in the ocean.  Yesterday, I even tried surfing!

Why am I telling you all this??

Well….Full immersion of the face in cold water (via a jump into the ocean, or otherwise) immediately activates the Mammalian Diving Response.  Why is this interesting? Read on…..

Did you know that our Mammalian Diving Response is the most powerful Autonomic Nervous System reflex known?  For example, this reflex immediately causes:

– Decreased heart rate;

– Vasoconstriction in the periphery (shunting of blood away from the arms and legs, and into the heart, brain and other organs); and

– Apnea/breath-holding, while underwater.

The Mammalian Diving Response can immediately be activated during a ‘relaxing’ cold plunge pool immersion, and also while snorkelling, free diving, and scuba diving in the ocean.

James Nestor, author of Deep, describes the Mammalian Diving Response in the following awe-inspiring 3-minute YouTube:

In sports medicine, Contrast Cold/Warm Water Baths (including full-body immersion) are often used to treat soft tissue and joint injuries.  This treatment promotes alternating vasodilation/vasoconstriction (almost like a ‘pumping action’).  This therapy can reduce swelling, pain and muscle spasm, while also increasing peripheral circulation.

A Turkish review paper discussed the benefits of Cold and Heat Therapy in Fibromyalgia patients.  

Mankind has practised Ice Cold/Cold/Cool/Warm/Hot Water Immersion Therapy (Contrast Water Immersion Therapy) for as long as we can remember.  For example, native Indians often soaked in natural hot springs and washed in cold lakes and rivers.

Immersion in plunge pools with varying water temperatures can give our Autonomic Nervous System a very good work-out.  Blood circulation is re-directed back and forth, from the legs/arms to the heart, brain and other organs (while immersed in cold water), and back to the legs and arms (while immersed in warm water).

You could think of Contrast Hot/Cold Water Immersion Therapy as being like a gym workout for your Autonomic Nervous System!

Immersion in cooler/cold water is a quick, simple, and effective way to re-activate our parasympathetic nervous system (including efferent vagus nerve).  It causes our heart rate to slow and our breathing rate to decrease.  At the same time, blood circulation is diverted away from our arms and legs, and into our organs including heart and brain.

Chronic pain conditions are often associated with localised inflammation, an overactive sympathetic nervous system, an underactive parasympathetic nervous system including reduced efferent vagal output, and reduced heart rate variability.

QUESTIONS: 

Would Cool Water Therapy (including brief facial immersion) lead to increased parasympathetic nervous system activity, reduced inflammation, and reduced pain?  

Could Contrast Cold/Warm/Hot Water Therapy also result in decreased pain?  

Under what circumstances does increased pain occur?

NOTE:  When warranted, this water-based therapy should always be medically supervised.

Wishing you all a good weekend!

Sabina Walker

REFERENCES

(1) Cochrane; Alternating hot and cold water immersion for athlete recovery: A review; Physical Therapy in Sport (2004), 5, Pages 26-32.

http://wingate.org.il/_Uploads/345485hot%20and%20cold%20baths.pdf

(2) Al Haddad et al; Effect of cold or thermoneutral water immersion on post-exercise heart rate recovery and heart rate variability indices; Autonomic Neuroscience: Basic and Clinical (2010), 156(1-2), Pages 111-116.

http://www.ncbi.nlm.nih.gov/pubmed/20403733

(3) Buchheit et al; Effect of cold water immersion on postexercise parasympathetic reactivation; American Journal of Physiology. Heart and Circulatory Physiology (2009), 296(20), Pages H421-427.

http://www.ncbi.nlm.nih.gov/pubmed/19074671

(4) Aysegul Jale Sarac and Ali Gur; Complementary and Alternative Medical Therapies in FibromyalgiaCurrent Pharmaceutical Design (2006), 12, 47-57 47

http://www.neurofeedbackclinic.ca/journals/fibromyalgia/19239028.pdf

(5) Panneton et al; Parasympathetic preganglionic cardiac motoneurons labeled after voluntary diving. Front Physiol. 2014 Jan 28;5:8. doi: 10.3389/fphys.2014.00008

http://www.ncbi.nlm.nih.gov/pubmed/24478721

MORE ON THE MAMMALIAN DIVING RESPONSE

(From a free-diving perspective) 

(6) Nestor, James; Deep – Freediving, Renegade Science and What the Ocean Tells Us About Ourselves; 2014 http://www.amazon.com/Deep-Freediving-Renegade-Science-Ourselves/dp/0547985525

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CRPS and Phantom Limb Pain Treated with Memantine or Memantine/Morphine

Dear Pain Matters blog readers,

COMPLEX REGIONAL PAIN SYNDROME (CRPS) AND MEMANTINE

Three (3) German studies (by the same team) showed promising results following:

– Memantine; or

– Memantine/Morphine Combination Therapy

in CRPS patients.

(1) 1st Study –

In the 1st study, pain decreased in 3 CRPS patients (CRPS duration = 1 to 7 months) following oral Memantine treatment for 8 weeks.  Specifically, there was NIL ‘resting pain’ at the 6-month follow-up (Sinis et al, 2006).

(2) 2nd Study –

In 6 CRPS patients, the duration of CRPS ranged from 4 to 23 months before Memantine Treatment.

Pain decreased significantly, and ‘continuous pain’ disappeared in all 6 CRPS patients after 8-week Memantine Treatment (as at 6-month follow-up).   Motor function also improved, together with Autonomic Nervous System changes, in all 6 patients (Sinis et al, 2007).

(3) 3rd Study –

This study involved 20 CRPS patients, as follows:

– 10 were given ‘Memantine/Morphine Combination Therapy’; and

– 10 were given ‘Placebo + Morphine’.

Duration of CRPS ranged from 6 to 36 months.

In all 10 CRPS patients, ‘pain at rest’ and ‘pain during movement’ decreased significantly following Memantine/Morphine Combination Treatment for 8 weeks. 

Interestingly, the 10 patients who were not given Memantine (the ‘Placebo + Morphine’ group) did not benefit as much.

Only the 10 patients given Memantine/Morphine Combination Treatment for 8 weeks had significant pain reduction and reduced disability.  

… and guess what else happened (that is very interesting)??

Memantine/Morphine Combination Treatment also resulted in significantly reduced activity in certain brain regions (Primary Somatosensory Cortex – contralateral side (S1) and Anterior Cingulate Cortex) when the CRPS-hand was moved!

Thus, Memantine/Morphine Combination Treatment resulted in decreased pain.  Furthermore, this decreased pain was mirrored via reduced activity in certain brain regions (S1, S2) (Gustin et al, 2010).  

PHANTOM LIMB PAIN AND MEMANTINE

Two (2) patients had severe Phantom Limb Pain as a consequence of severe lower leg injuries.  When oral Memantine treatment was given, these 2 patients had significant reduction in Phantom Limb Pain (Hackworth et al, 2008).  More studies are needed.

SUMMARY

In summary, treatment involving Memantine or Memantine/Morphine warrants more attention given its impressive results in:

– (a total of) 19 CRPS patients; and

– 2 patients with Phantom Limb Pain

who received either Memantine alone or Memantine/Morphine.  

Sabina Walker

PS  YOU DON’T HAVE TO READ THE FOLLOWING UNLESS YOU ARE VERY INTERESTED IN SCIENCE –

POSSIBLE MECHANISMS OF MEMANTINE IN NERVE PAIN

Memantine/Morphine Combination Therapy may alleviate painful symptoms of CRPS by reducing tumor necrosis factor-α (TNF) and other inflammatory mediators.  An animal study reported that administration of Memantine Hydrochloride decreases TNF expression in rats.  Studies are warranted to determine whether Memantine decreases local TNF in pain patients including CRPS patients.  (Memantine is widely known for its antagonistic effects on the NMDA receptor.)

(Please refer to Review Paper by Sabina Walker and Prof. Peter Drummond for further details.  In particular, please refer to pages 1796 – 1797, plus 4 Memantine-related References on pages 1805-1806, plus papers below.)

REFERENCES:

COMPLEX REGIONAL PAIN SYNDROME (CRPS) AND MEMANTINE

(1) Gustin SM, Schwarz A, Birbaumer N, et al. NMDA-receptor antagonist and morphine decrease CRPS-pain and cerebral pain representation. Pain 2010;151:69–76.

http://www.rsds.org/pdfsall/Gustin_Pain_2010.pdf

(2) Sinis N, Birbaumer N, Gustin S, et al. Memantine treatment of complex regional pain syndrome: A preliminary report of six cases. Clin J Pain 2007;23: 237–43.

http://www.rsds.org/pdfsall/Sinis_Birbaumer_Gustin.pdf

(3) Sinis N, Birbaumer N, Schwarz A, et al. Memantine und komplexes regionales Schmerzsyndrom (CRPS): Behandlungseffekte und kortikale Reorganisation (Memantine and complex regional pain syndrome (CRPS): Effects of treatment and cortical reorganisation). Handchir Mikrochir Plast Chir 2006;38:164–71. (in German).

http://www.researchgate.net/publication/239488100_Memantine_und_komplexes_regionales_Schmerzsyndrom_(CRPS)_Behandlungseffekte_und_kortikale_Reorganisation

(4) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

In particular, please refer to pages 1796 – 1797, plus 4 Memantine-related References on pages 1805-1806.

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract

(5) Park et al; Antinociceptive Effect of Memantine and Morphine on Vincristine-induced Peripheral Neuropathy in Rats; Korean Journal of Pain (Sept 2010); 23(3):179-185.

doi: 10.3344/kjp.2010.23.3.179.

PHANTOM LIMB PAIN AND MEMANTINE 

(6) Hackworth et alProfound pain reduction after induction of memantine treatment in two patients with severe phantom limb pain; Anesth Analg (2008); 107:1377–1379.

Nabilone for Chronic Pain Including Nerve Pain (eg CRPS)

Dear Pain Matters blog readers,

Dr Mark Ware, McGill University in Montreal, reported that Nabilone (‘Cesamet’), an oral synthetic cannabinoid, may offer some pain relief in both cancer and non cancer pain.  

Specifically, Nabilone may help alleviate painful symptoms in patients with:

– Nerve pain (e.g. complex regional pain syndrome, CRPS);

– Multiple sclerosis;

– Fibromyalgia; 

– Other chronic non cancer pain (eg postoperative or traumatic pain, arthritis, Crohn’s disease, interstitial cystitis, HIV-associated myopathy, post-polio syndrome, idiopathic inguinal pain, and chronic headaches); and

– Cancer pain.

Dr May Ong-Lam reported that in 10 patients with refractory CRPS, Nabilone treatment resulted in up to 60% pain reduction.  Opioids and other pain medication were no longer required by 7 patients following Nabilone therapy.  Improved quality of life and better sleep resulted.  Nabilone treatment resulted in improved physical ability including the ability to bear weight, resume work, and perform housework.  There were few side effects, and patients did not develop tolerance to Nabilone.

Prior to Nabilone treatment, and despite receiving many different pain medications, these 10 CRPS patients suffered burning painallodynia, autonomic nervous system changes, and physical disability.  Pre-Nabilone, all 10 CRPS patients ranked CRPS pain as 10 out of 10 (on 10-point visual analog scale; VAS).

Importantly, post-Nabilone therapy, overall pain decreased to 3 – 6 (on VAS) in all 10 CRPS patients.

Fibromyalgia patients reported that Nabilone offered significant benefits in pain relief and functional improvement.

A cancer pain study reported that pain scores in Nabilone-treated cancer patients were significantly reduced, compared to those who were not treated with Nabilone.  Other improvements in Nabilone-treated cancer patients included reduced nausea, less anxiety/overall distress, and slight improvement in appetite.  Nabilone-treated cancer patients were also able to reduce (or discontinue) dosages of other drugs including nonsteroidal anti-inflammatory agents, tricyclic antidepressants, and gabapentin.

A cannabis extract may be used to treat refractory spasticity in multiple sclerosis.

POSSIBLE MECHANISMS

Cannabinoid agonists (including Nabilone) activate cannabinoid receptor types CB1 and CB2.  Activation of CB2 leads to anti-inflammatory effects including reduction of TNF-alpha-induced endothelial cell activation, monocyte migration and adhesion.  This may partly explain why cannabis and cannabinoids are able to reduce pain including nerve pain (CRPS, multiple sclerosis).

For more posts on medical cannabis (aka medical marijuana) as well as cannabis-based pain medication (eg Sativex), please see:

https://painmatters.wordpress.com/2016/09/22/medical-cannabis-medical-marijuana-and-nerve-pain/

and

https://painmatters.wordpress.com/2017/04/10/lets-talk-to-an-inspirational-young-woman-paula-orecklin-about-crps-sativex-physiotherapy-and-neuroplasticity/

Wishing less pain to all pain patients,

Sabina Walker

References:

(1) Mark A. Ware; Cannabinoids in Pain Management: An Update from the 2009 Canadian Pain Society Meeting, Quebec QC

http://www.ccic.net/picture/upload/File/Viewpoints/Viewpoints_in_Cannabinoids_MASTER.pdf

(2) Berlach, Shir, Ware. Experience with the synthetic cannabinoid nabilone in chronic noncancer painPain Med. 2006 Jan-Feb;7(1):25-9.

http://www.rsds.org/pdfsall/Experience%20with%20the%20synthethic%20cannabinoid%20nabilone.pdf

(3) David Wild; Refractory CRPS Patients Discontinue Opiates With Cannabinoid Treatment (A Study by May Ong-Lam, MD, Clinical Assistant Professor, Dept of Medicine, St Paul’s Hospital, Vancouver); Pharmacy Practice News (8 Feb, 2011).

http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=239&i=January+2011&i_id=694&a_id=16601

(4) Skrabek RQ, Galimova L, Ethans K, Perry D; Nabilone for the treatment of pain in fibromyalgia. J Pain 2008;9(2):164-173.

http://www.ncbi.nlm.nih.gov/pubmed/17974490

(5) Maida et al, 2008. Adjunctive nabilone in cancer pain and symptom management: a prospective observational study using propensity scoring. J Support Oncol. 2008 Mar;6(3):119-24.

http://www.ncbi.nlm.nih.gov/pubmed/18402303

(6) Grotenhermen, Müller-Vahl; The therapeutic potential of cannabis and cannabinoidsDtsch Arztebl Int (2012 July);109(29-30):495-501.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442177/

(7) Rajesh et alCB2-receptor stimulation attenuates TNF-alpha-inducedCB2-receptor stimulation attenuates TNF-alpha-induced human endothelial cell activation, transendothelial migration of monocytes, and monocyte-endothelial adhesion; Am J Physiol Heart Circ Physiol (2007 Oct);293(4):H2210-8.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2229632/

Heart Rate Variability and Non Pain Medical Researchers Who Fully Embrace HRV Studies – Why Don’t We?

Dear Pain Matters blog readers,

Who has pain? 

Here are some sobering statistics:

Moderate to severe intensity of chronic pain affects 1 in 5 (19%) adults in Europe, hence adversely impacting on the social and working lives of these chronic pain sufferers.  Furthermore, 6.9% – 10% of the population suffers from nerve pain (neuropathic pain).  Other studies report the incidence of nerve pain closer to 7% – 8%.  In cancer, nerve pain affects 2 in 5 (39%) cancer patients with pain.

So if you suffer from nerve pain and/or chronic pain, you are certainly not alone!

Heart Rate Variability (HRV)

Given the vast numbers of nerve pain and/or chronic pain sufferers, research into heart rate variability (HRV) and its potential usefulness as an (additional) diagnostic tool for the assessment of pain intensity is warranted.

The measurement of HRV may (also) be useful to assess the effectiveness of pain treatments, ‘before‘, ‘during‘, and ‘after‘ treatments including pain medication.

Heart rate variability monitoring is non-invasive and relatively inexpensive.  Real-time HRV data can even be collected in the privacy of a pain patient’s own home (via a small device) for a certain period of time (minutes, hours, or even days at a time) by the pain researcher.  This data can be downloaded, and forwarded for HRV analysis at a centralized medical/research location (see papers by Litscher et al).

While selected studies involving HRV and pain are published, many more studies involving pain and HRV are needed.  Research funding should be directed into HRV and nerve pain/chronic pain/acute pain/cancer pain.

There are many HRV experts including Thayer et al and Litscher et al.  However, most of these HRV experts are  dedicated to non pain research.

For example, an entire section in a journal called Evidence-Based Complementary and Alternative Medicine is solely dedicated to studies involving HRV.  This section, called Heart Rate Variability and Complementary Medicine 2014, lists seventeen (17) HRV-related studies (see References)!

In my humble opinion, it would be nice to see a similarly long and impressive list of studies solely dedicated to HRV and nerve pain/chronic pain.

Heart rate variability monitoring in pain patients may complement current diagnostic methods including the McGill Pain Questionnaire.

Finally, comparison of HRV results ‘before‘, ‘during‘, and ‘after‘ pain treatments may offer additional insight into the effectiveness of these pain treatments including pain medication.

Sabina Walker

Master Appl. Science (Neuroscience)

With an academic interest in ‘HRV and Nerve Pain’

References:

References for ‘Who has pain?’:

(1) Breivik et al; Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment; Eur J Pain (May 2006); 10(4), Pages 287-333.

http://www.ncbi.nlm.nih.gov/pubmed/16095934

(2) van Hecke et al; Neuropathic pain in the general population: A systematic review of epidemiological studies; Pain (April 2014); 155(4), Pages 654-662.

http://www.painjournalonline.com/article/S0304-3959(13)00610-6/abstract

(3) Piano et al; Treatment for neuropathic pain in patients with cancer: comparative analysis of recommendations in national clinical practice guidelines from European countries; Pain Pract (Jan 2014); 14(1), Pages 1-7.

doi: 10.1111/papr.12036.

http://www.ncbi.nlm.nih.gov/pubmed/23360414

References for ‘Heart Rate Variability (HRV)’:

 

(4.0) Litscher G, He W, Yi S-H, Wang L (Guest Editors);

Heart Rate Variability and Complementary Medicine 2014 (Annual Special Issue); Evidence-Based Complementary and Alternative Medicine.

Includes the following HRV-related papers:

(4.1) Impact of Colored Light on Cardiorespiratory Coordination

(4.2) Auricular Acupressure to Improve Menstrual Pain and Menstrual Distress and Heart Rate Variability for Primary Dysmenorrhea in Youth with Stress

(4.3) The Influence of New Colored Light Stimulation Methods on Heart Rate Variability, Temperature, and Well-Being: Results of a Pilot Study in Human

(4.4) Pilot Study of Acupuncture Point Laterality: Evidence from Heart Rate Variability

(4.5) Manual Acupuncture and Laser Acupuncture for Autonomic Regulations in Rats: Observation on Heart Rate Variability and Gastric Motility

(4.6) Heart Rate Variability and Hemodynamic Change in the Superior Mesenteric Artery by Acupuncture Stimulation of Lower Limb Points: A Randomized Crossover Trial

(4.7) Effectiveness of Interstitial Laser Acupuncture Depends upon Dosage: Experimental Results from Electrocardiographic and Electrocorticographic Recordings

(4.8) Continuous Auricular Electroacupuncture Can Significantly Improve Heart Rate Variability and Clinical Scores in Patients with Depression: First Results from a Transcontinental Study

(4.9) Improvement of the Dynamic Responses of Heart Rate Variability Patterns after Needle and Laser Acupuncture Treatment in Patients with Burnout Syndrome: A Transcontinental Comparative Study

(4.10) The Physical Effects of Aromatherapy in Alleviating Work-Related Stress on Elementary School Teachers in Taiwan

(4.11) Auricular Acupuncture at the “Shenmen” and “Point Zero” Points Induced Parasympathetic Activation

(4.12) Laser Acupuncture: Two Acupoints (Baihui, Neiguan) and Two Modalities of Laser (658 nm, 405 nm) Induce Different Effects in Neurovegetative Parameters

(4.13) Effects of Acupuncture on Heart Rate Variability in Beagles; Preliminary Results, Huan Wang, Gerhard Litscher, Xian Shi, Yue Bo Jiang, and Lu Wang

(4.14) Heart Rate Variability and Complementary Medicine

(4.15) Effect of Acupuncture on Heart Rate Variability: A Systematic Review

(4.16) Intravenous Laser Blood Irradiation, Interstitial Laser Acupuncture, and Electroacupuncture in an Animal Experimental Setting: Preliminary Results from Heart Rate Variability and Electrocorticographic Recordings

(4.17) Ear Acupressure, Heart Rate, and Heart Rate Variability in Patients with Insomnia

http://www.hindawi.com/journals/ecam/variability.complementary.medicine/

(5.1) In English –

Krzysztof Kudryski

Analysis of Heart Rate Variability Signal

ISBN10 3838372360
ISBN13 9783838372365

(5.2) In German –

Jens-Falk Heimann, Nicole Franke-Gricksch

Der Puls des Lebens – Die Signale des Herzens verstehen (2015; 208 pages)

ISBN-13: 9783944697024
ISBN-10: 3944697022

CRPS Video on CRPS by PARC (a CRPS website)

Dear Pain Matters blog readers,

An excellent, 20-minute documentary video (available on DVD) about the impact of complex regional pain syndrome (CRPS) on 4 CRPS sufferers has just been brought to my attention.

This video/DVD is called:

DVD: LIVING A LIFE IN PAIN:

THE STORY OF RSD/CRPS

By Sarah Panas

This DVD, by film maker, Sarah Panas (Winnipeg, Manitoba), can be ordered from PARC for $10 plus shipping:

http://www.rsdcanada.org/parc/english/parc/news.htm

 

This video is also accompanied by a 5-minute trailer:

Living a Life in Pain: The Story of RSD/CRPS – Trailer’:

http://www.youtube.com/watch?v=uB1TPVND9iU

 

Four (4) CRPS patients are featured in this documentary, plus trailer.

Pain Specialist (Dr David Shulman) and Psychologist (Dr Matthew Bailly) are also interviewed.  It is worth adding that in 2008, Dr Shulman rode halfway across Canada on a bicycle, totalling 3,750 km, to raise funds for CRPS research!

Here is a sample of eye-opening comments about CRPS made by the 4 CRPS patients (excerpts only – see video and trailer for full comments):

CRPS Patient #1, Richard Panas, who uses a cane and a wheelchair due to CRPS, describes the painful experience of CRPS as follows (quoting):

“…. RSDS [aka CRPS] …..is a nightmare!  It’s the worst thing ever! …..I could have plans to go somewhere, and I can’t even walk! ….and I don’t think there’s too many people that’ve been in that amount of pain………I used to explain the pain in my leg like someone ripped open my skin and was scraping the bones with a spoon, and it was the best way I could explain the pain…..and if it wasn’t for my kids, Sarah and Jamie, I really believe I wouldn’t be here.”

CRPS Patient #2, Paula Orecklin, a young CRPS patient who uses a cane due to CRPS, describes CRPS as follows (quoting):

“….At this point, I am literally waiting for the next medical breakthrough.  I’m waiting for the next paper, because I have tried it all…..Even though you can’t see my disease, it is there.  Believe me when I say it! … This is as much pain as you can be in, and keep going, as far as I can tell….It’s hard to look in my future and be all that optimistic, sometimes.”

CRPS Patient #3, Willy Noiles, CRPS patient and PARC Board Member, adds (quoting):

“I would describe the pain as a burning pain. It’s almost like your leg is on fire at times, and at other times, it’s almost like someone is jabbing something into you.”

CRPS Patient #4, Helen Small, CRPS patient and PARC Executive Director, states (quoting):

“The pain is out of proportion to the injury.  So if you drop a coffee jar on your foot and you can’t walk, people don’t believe you….”

Some sobering statistics are also provided in the 5-minute trailer (quoting a sample):

“1 in 60 has a lifetime risk of getting RSD/CRPS…..”

“There is no cure, or way to test for it.”

(Note to blog readers:  More on this in future blog posts…)

“Reflex Sympathetic Dystrophy Syndrome, or Complex Regional Pain Syndrome (RSD/CRPS) is a neuropathic pain condition.”

“Treatments vary from analgesics, opioids, antidepressants to medical marijuana.”

So where to from here?

We know that there are 1000’s of CRPS patients in the world.

The good news is that there are also 1000’s of pain researchers as well as 1000’s of pain specialists out there.

On top of this, there are millions and millions of compassionate people.

So let’s all put our heads together, and see what we can collectively come up with to help patients with CRPS as well as other nerve pain disorders.

Let’s end on a positive note today, and tell these CRPS patients that they are not alone.  We will be there for them, and with them.

This Pain Matters blog is about finding papers and articles that may offer hope and inspiration for CRPS patients, as well as other patients with nerve pain.

Sabina Walker

Impaired Motor Function Caused by Pain – Reversible Following Analgesia

Dear Pain Matters blog readers,

In some pain patients, the source of pain may emanate from a finger, hand, arm, toe, foot, ankle or leg.  This pain may be sooooo painful that physiotherapy is simply not possible.

In the following case, physiotherapy was finally rendered possible following a novel pharmaceutical block.

SUCCESSFUL CASE STUDY:

A 54-year old man suffered intense pain and an inability to flex his index finger following an operation for a proximal phalangeal fracture.

Dr Maxwell and his colleagues were able to perform an ultrasound-guided continuous median nerve block in the proximal forearm of the pain patient.  This led to a temporary and successful block of all sensation including elimination of intense pain in the median nerve distribution for 11 consecutive days.

Importantly, motor function remained unaffected by this ultrasound-guided block of a selected terminal nerve branch.  This enabled the patient to fully participate in hand physical therapy that resulted in successful rehabilitation to restore flex function to his index finger.

Oral opioid medication was also discontinued (Maxwell et al, 2013).

(Conventional blocks often block both sensory and motor pathways, the latter preventing physical therapy to be undertaken due to block-induced temporary loss of motor function.)

SUMMARY:

Intense pain can hinder and even sabotage rehabilitation including motor re-training efforts.

Take away the pain temporarily (via a pharmaceutical block) … et voilà … physiotherapy is finally possible!  Thus, treatment should be aimed at blocking the pain first before commencing physical therapy.

In other words, ultrasound-guided perineurial catheters may be useful for targeting terminal branches of nerves and blocking pain without affecting motor function.  This may enable physical therapy to finally proceed in the absence of pain.

The absence of pain may also lead to plasticity in the brain.  Pain relief via block may also enable the autonomic nervous system to ‘recalibrate itself’ leading to improved parasympathetic activity.

Wishing less pain to more people,

Sabina Walker,

Blogger, Pain Matters (in WordPress)

FOR PAIN ACADEMICS:

Certain chronic pain conditions (eg complex regional pain syndrome, CRPS) may also involve impaired motor function.  This results in reduced muscle (grip) strength, decreased skeletal muscle activity and muscle loss/wastage due to inactivity of the painful limb.

When intense pain affects motor function including skeletal muscle weakness, this is called ‘nociception/motor interaction‘.

Inhibited visceromotor function including inhibition of cutaneous sympathetic vasoconstriction was observed in the CRPS-affected limb.  This can cause shunting of blood away from the capillaries, impaired capillary blood circulation and hypoxia in the CRPS limb, followed by intense pain (Wasner et al, 2001).

Question:

Does inhibition of muscle sympathetic nerve activity (MSNA) also occur in CRPS?  If yes, does inhibited MSNA contribute to weakened skeletal muscle strength in CRPS?  After all (as noted above), inhibition of cutaneous sympathetic vasoconstriction occurs in CRPS.  Research is warranted.

Reduced efferent vagal outflow may also contribute to localized inflammation and a prolonged and repetitive pain/inflammation cycle.

Other neural circuits including afferent pathways may also be impaired.

REFERENCES:

(1) Maxwell et al. Ultrasound-guided Continuous Median Nerve Block to Facilitate Intensive Hand Rehabilitation. Clinical Journal of Pain (January 2013); 29(1): 86–88.

doi: 10.1097/AJP.0b013e318246d1ca

http://www.ncbi.nlm.nih.gov/pubmed/22751029

(2) Nijs et al. Nociception Affects Motor Output: A Review on Sensory-Motor Interaction With Focus on Clinical Implications. Clinical Journal of Pain (February 2012); 28(2): 175–181.

doi: 10.1097/AJP.0b013e318225daf3

http://www.ncbi.nlm.nih.gov/pubmed/21712714

(3) Wasner G, Schattschneider J, Heckmann K, Maier C, Baron R. Vascular Abnormalities In Reflex Sympathetic Dystrophy (CRPS I): Mechanisms And Diagnostic Value. Brain (2001); 124: 587–599.

More on Music and Pain

Dear Pain Matters blog readers,

More on relaxing music and pain –

A study by Peter Vuust et al (Aarhus University, Denmark) found that in 22 fibromyalgia patients, (1) the intensity of pain as well as (2) its unpleasantness (‘pain affect’) were both reduced after listening to their favourite (self-selected) relaxing music.

In other words, because this self-chosenrelaxing music was considered pleasant by the patients (likely, evoking positive emotions), it resulted in reductions in both the intensity of pain as well as the unpleasantness of pain in fibromyalgia patients.

Consequently, pain management strategies that also include relaxing and pleasant (self-selected) music therapy may enable pain medication dosages to be reduced, hence reducing side effects from medication.

Improvement in mobility was also noted following music therapy.

Another study by Guétin et al also confirmed the benefits of music therapy as an additional pain management strategy for chronic pain patients.  This study involved 87 chronic pain patients including patients with lower back pain and fibromyalgia (reference below).

It is possible that increased parasympathetic nervous system activity results when we listen to our own favourite relaxing and pleasant music (and/or pursue other deeply relaxing therapies/hobbies each day).  This may increase efferent vagus nerve activity that leads to decreased local inflammation….and hence, reduced inflammatory pain (more later).

Further research is warranted whether relaxing and pleasant music therapy leads to specific physiological effects including:

– reduced heart rate,

– increased heart rate variability, and

– reduced respiratory rates/deeper breath intakes

in chronic pain patients.  The consequence of these physiological effects may equate to reduced intensity of pain.

If you’d like to listen to the relaxing songs that were selected by the fibromyalgia patients, they are listed in the back of the paper by Garza-Villarreal et al (Table 2 in the Appendix).  A small sample from this Table 2 is also provided below:

Secreto de Amor

Vivaldi – Four Seasons – Spring Allegro Pastorale

So blog readers, what are your favourite relaxing and pleasant songs?

Until soon,

Sabina Walker

PS  I would like to share the latest press release on this topic (13 August 2015):

Music improves recovery and lowers pain after surgery, says study published in the Lancet

http://www.smh.com.au/national/health/music-improves-recovery-and-lowers-pain-after-surgery-says-study-published-in-the-lancet-20150812-gixprn.html

References:

(1) Garza-Villarreal et al; Music reduces pain and increases functional mobility in fibromyalgia; Front Psychol (Feb 2014); 5:90.

doi: 10.3389/fpsyg.2014.00090

http://www.readcube.com/articles/10.3389/fpsyg.2014.00090

(2) Music can relieve chronic pain. Science Nordic (March 25, 2014)

http://sciencenordic.com/music-can-relieve-chronic-pain

(There is also a Danish link.)

(3) Guétin et al; The Effects of Music Intervention in the Management of Chronic Pain: A Single-Blind, Randomized, Controlled Trial;

Clinical Journal of Pain (May 2012); 28(4); Pages 329–337.

doi: 10.1097/AJP.0b013e31822be973

http://journals.lww.com/clinicalpain/Abstract/2012/05000/The_Effects_of_Music_Intervention_in_the.8.aspx

(4a) Hole et al; Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis; Lancet.

DOI: http://dx.doi.org/10.1016/S0140-6736(15)60169-6

(4b) Dreaper; Music ‘reduces pain and anxiety’ for surgery patients; BBC News (13 August 2015).
http://www.bbc.co.uk/news/health-33865448