Pain Management

This section was compiled by Frank M. Painter, D.C.
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Pain-related Articles

Spinal Manipulative Therapy and Its Role in the Prevention,
Treatment and Management of Chronic Pain

J Canadian Chiro Assoc 2012 (Mar);   56 (1):   5-7 ~ FULL TEXT

Chronic pain is a worldwide epidemic. It is characterized as “pain that persists beyond normal tissue healing time” [1] and is physiologically distinct from acute nociceptive pain. The current research estimates the prevalence of chronic pain in the general population to be anywhere from 10–55%, [2] predominantly affecting the adult population. Studies indicate that the prevalence of chronic pain in the over-60 age group is double that for younger adults. [3] Furthermore, over 80% of elderly (over 65) adults suffer from some form of painful chronic joint disease [4] and greater than 85% of the general population will experience some form of chronic myofascial pain during their lifetime. [5]

Recognizing the Value of Chiropractic for Chronic Pain
Dynamic Chiropractic 2008 (Sep 23);   26 (20):

The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.

Psychosocial Factors and their Role in Chronic Pain:
A Brief Review of Development and Current Status

Chiropractic & Osteopathy 2005 (Apr 27);   13 (1):   6 ~ FULL TEXT

The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.

Alternatives in Cancer Pain Treatment:
The Application of Chiropractic Care

Semin Oncol Nurs 2005 (Aug);   21 (3):   184–189

The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall. You'll find more articles like this in the Chiropractic And Cancer Page.

Chronic Pain in Persons With Neuromuscular Disease
Clin J Pain 2005 (Jan);   21 (1):   18–26

In this paper, researchers in a medical school rehabilitation department were interested in finding out what treatments were most effective at reducing pain for neuromuscular diseases (like amyotrophic lateral sclerosis and myotonic muscular dystrophies). Interestingly, chiropractic scored the highest relief rating (7.33 out of 10), scoring higher than the relief provided by these medical treatments: nerve blocks (6.75) or Opioid analgesics (6.37). WOW!!!

Qualitative Review of Studies of Manipulation-induced Hypoalgesia
J Manipulative Physiol Ther 2000 (Feb);   23 (2):   134–138

From the early 1990s, there are several reports involving the use of the pressure algometer initially devised by Fischer.[24] Vernon [25] was the first to report the improvement in paraspinal pressure pain threshold (PPT) levels after manipulation. Six tender muscle spots were measured bilaterally in a subject with chronic right-sided neck and scapular pain. The right side muscle values were all significantly lower than those on the left and were lower than the normal cut-off value of 3.5 kg/cm2 established by Fischer. [24] After a cervicoscapular manipulation, PPT levels rose by an average of 45%, whereas the patient's pain score dropped from 6 to 1/10 on a 10-centimeter VAS. In 1992, Vernon et al [12] reported on 9 subjects with chronic neck pain. Baseline PPT values were obtained bilaterally around the painful segment (fixation) for a total of 4 measured sites. Five subjects were randomly assigned to receive a rotary manipulation, and 4 subjects received the same sort of oscillatory mobilization that had been used in the endorphin study. [21] In the group receiving manipulation, PPT levels at 5 minutes after treatment rose at all 4 sites (ie, bilaterally) an average of 45%, whereas in the control group there was no increase. This difference was statistically significant at all 4 points.

Recent Considerations in Nonsteroidal Anti-inflammatory Drug Gastropathy
American Journal of Medicine 1998 (Jul 27);   105 (1B):   31S-38S

Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone. The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated. Analysis of these data indicates that:   (1)   osteoarthritis (OA) and rheumatoid arthritis (RA) patients are 2.5—5.5 times more likely than the general population to be hospitalized for NSAID-related GI events;   (2)   the absolute risk for serious NSAID-related GI toxicity remains constant and the cumulative risk increases over time;   (3)   there are no reliable warning signals- >80% of patients with serious GI complications had no prior GI symptoms;   (4)   independent risk factors for serious GI events were age, prednisone use, NSAID dose, disability level, and previous NSAID-induced GI symptoms; and   (5)   antacids and H2 antagonists do not prevent NSAID-induced gastric ulcers, and high-risk NSAID users who take gastro-protective drugs are more likely to have serious GI complications than patients not taking such medications. Currently, limiting NSAID use is the only way to decrease the risk of NSAID-related GI events.

Cartilage Maintenance in Osteoarthritis: Interaction of Cytokines, NSAID and
Prostaglandins in Articular Cartilage Damage and Repair

J Rheumatol Suppl 1991 (Mar);   28:   30–37

Evidence is presented that animal and human cartilages are sensitive to the action of certain nonsteroidal antiinflammatory drugs (NSAID) in inhibiting the synthesis of cartilage proteoglycan and also diminishing the repair activity of cartilage recovering after IL-1. In OA cartilage, the sensitivity to action of NSAID may depend on the state of the tissue in terms of glycosaminoglycan (GAG) turnover and GAG synthetic activity of the indigenous chondrocytes. Preliminary investigations of the prostaglandin analog misoprostol on the synthetic repair activities of animal and human cartilage in the presence of NSAID are reported.

Pain Has Significant Negative Effects on Health and Workplace Productivity
J Occupational and Environmental Medicine 2005 (Jul);   47 (7):   658–670

Pain is one of the leading causes of both worker absenteeism, in which an employee must take time away from work, and worker "presenteeism," in which an employee's overall effectiveness at work is limited as a result from physical and/or mental health problems. The effect pain can have on both employees and employers continues to increase significantly; by some estimates, common pain conditions now account for more than $62 billion per year in lost productivity.

Treatment Expectancy Affects the Outcome of Cognitive-Behavioral
Interventions in Chronic Pain

Clin J Pain 2005 (Jan);   21 (1):   18–26

Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain.

Pain Costs Employers Billions in Lost Wages for Sick Days
American employers lose billions of dollars each year because pain keeps workers off the job, according to a 1996 survey by Louis Harris & Associates. "Pain is a major cause of absenteeism in the workforce," said Robert Leitman, Executive Vice President, Louis Harris. "In 1995, pain caused 50 million lost work days at a cost to employers of at least $3 billion in wages for employees who called in sick."

In The Opinion of Drug Companies

Pain and Older Americans Survey
One in five Americans over age 60 takes medication to control pain that lasts for six months or more (chronic pain). This represents 18% of Americans in this age group, or 7.5 million people.

Nearly One in Five Seniors Takes Medication for Chronic Pain
Nearly one in five Americans over age 60 regularly takes medication for chronic pain, according to a 1997 survey. The majority of the 7.5 million seniors who take medication for chronic pain say their medications are effective, but one in four suffers from side effects caused by the drugs. Nearly 40 percent say doctors don't discuss possible side effects of pain medication they prescribe, and half say doctors don't warn them about potential drug interactions.

Pain Is Undertreated in Seniors, Experts Say
Safer, more effective therapy could improve the quality of life of older Americans who take pain medication. This conclusion was shared by pain specialists and experts on aging who reviewed findings of a survey released in June 1997 by The National Council on the Aging, Inc. (NCOA). The survey, conducted by Louis Harris & Associates on behalf of NCOA, examined how pain and its treatment affect the lives of the nearly one in five Americans over age 60 who regularly take pain medication for arthritis and other chronic pain conditions.

End of Opinion

1999 National Pain Survey ~ Executive Summary
Approximately 24 percent of Americans, or roughly 48 million people, suffer from chronic pain; 21.6 million Americans, or one in ten (11%) adults, take prescription pain medication regularly to manage chronic pain; Among individuals taking prescription pain medication, the most common types of chronic pain are arthritis (31%), lower back pain (25%), other types of bone/joint pain (17%), muscle pain or stiffness (13%) and fibromyalgia (12%).

Proving the Existance of Chronic Pain
Pain is ultimately a subjective experience. Proving the existence of pain is therefore, not possible. In practice, when a patient reports pain, the patient is believed to have pain. Yet, not all pain is the same. There may be a variety of reasons for reporting pain to a physician---pain, drug seeking, psychological problems, litigation needs---but there is always a reason. The critical issue is how to untangle the other factors from pain, recognizing that these factors may drive pain and pain may drive these factors.

From the Gate to the Neuromatrix
Pain 1999;   Suppl 6 Aug:   S121–126

The gate control theory's most important contribution to understanding pain was its emphasis on central neural mechanisms. The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. The dorsal horns, too, were not merely passive transmission stations but sites at which dynamic activities (inhibition, excitation and modulation) occurred. The great challenge ahead of us is to understand brain function.

Neuroanatomy of the Pain System and of the Pathways that Modulate Pain
J Clin Neurophysiol 1997 (Jan);   14 (1):   2–31

We review many of the recent findings concerning mechanisms and pathways for pain and its modulation, emphasizing sensitization and the modulation of nociceptors and of dorsal horn nociceptive neurons.

Substance P Induced by Peripheral Nerve Injury in Primary Afferent Sensory Neurons
and its Effect on Dorsal Column Nucleus Neurons

J Neurosci 1995 (Nov);   15 (11):   7633–7643

These data indicate that the de novo synthesized SP in the lesioned primary afferent neurons may be involved in an augmentation of excitability in the dorsal column-medial lemniscus sensory pathway. This hyperexcitability may play a role in the pathogenesis of abnormal neuropathic sensations following peripheral nerve injury.

Validity of Five Common Manual Neck Pain–provoking Tests
Scand J Rehabil Med 1995 (Sep);   27 (3):   131–136

This study revealed that palpation for pain was the most reproducable and accurate assessment of reported neck pain. They state: "Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self–reported questionnaires on dysfunctions of the neck."

Interexaminer Reliability of Palpation for Cervical Spine Tenderness
Scand J Rehabil Med 1995 (Sep);   27 (3):   131–136

As with the study above, spinal palpation for tenderness was found to ba a valid examinatioin tool. They stated: "In this population, palpation for cervical spine tenderness is a highly reliable examination tool."

Cartilage Maintenance in Osteoarthritis: Interaction of Cytokines,
NSAID and Prostaglandins in Articular Cartilage Damage and Repair

J Rheumatol Suppl 1991 (Mar);   28:   30–37

The structural integrity of the matrix of human articular cartilage is maintained by a dynamic equilibrium between synthesis and degradation. In osteoarthritis (OA), synthesis may be inhibited by the presence of subnanogram quantities of the cytokine interleukin 1 (IL-1), leading in the longterm to loss of matrix and susceptibility to mechanical damage. IL-1 may also inhibit the potential for repair processes to take place in this cartilage if continued synthesis and secretion of the cytokine occurs. Evidence is presented that animal and human cartilages are sensitive to the action of certain nonsteroidal antiinflammatory drugs (NSAID) in inhibiting the synthesis of cartilage proteoglycan and also diminishing the repair activity of cartilage recovering after IL-1.


Pain ~ Links of Interest

   American Pain Society   (APS)

   International Association for the Study of Pain

   National Headache Foundation

   NIH Consensus Statement on the Use of Acupuncture

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