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Naturally, We’re Rolling with It: Complimentary and Alternative Medicine in SCI Pain Management

Explore the use of Complimentary and Alternative Medicine (CAM) in spinal cord injury (SCI) pain management, including acupuncture, massage, and more. Learn about the benefits and risks associated with CAM therapies, and how they can complement traditional treatments for chronic pain in SCI patients. Discover the latest research on the effectiveness of CAM therapies in reducing neuropathic pain and improving quality of life for individuals with SCI.

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Naturally, We’re Rolling with It: Complimentary and Alternative Medicine in SCI Pain Management

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  1. 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

  2. No disclosures

  3. “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

  4. 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) Chronic Pain in SCI

  5. Classification • Nociceptive • Neuropathic • Other Pain (Felix 2014, Cardenas 2009) Overview of SCI Pain

  6. Over the counter • CAM therapies • Therapy / Exercise • SCI Pain • Opioids • Chronic pain medications • Neuropathic Pain Medications

  7. 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 (NorbringBudh 2004) Use of CAM in SCI

  8. 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 CAM Use at Penn State Hershey

  9. 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) Cochrane Review 2011

  10. The Basics

  11. 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) Diet

  12. Exercise is medicine: It can help. • Shoulder pain is reduced with a regular exercise program (Nawoczenski2006) Exercise

  13. Acupuncture

  14. Earliest recorded medical procedure in China • Believed to have started ~100 B.C. • Some developed use in other regions • Korea • Japan • Europe • France Origins and Status

  15. 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) Risk of Acupuncture

  16. Activation of various chemicals through • Peripheral • Spinal • Supraspinal mechanisms • Including • Opioids • Cytokines • Serotonin • Norephinephrine • N-methyl-D-aspartate (NMDA) GluN1 phosphorylation (Zhang 2014) Mechanisms of Acupuncture

  17. 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) Mechanisms in SCI for neuropathic pain

  18. Acupuncture and massage both showed benefit • Acupuncture was favored over time and sustained more patients. (Norrbrink 2011) Acupuncture versus Massage

  19. Some benefit seen examined by itself (Dyson-Hudson 2007) • Acupuncture and Trager show benefit individually in PU-WUSPI (Dyson-Hudson 2001) Acupuncture in SCI Shoulder Pain

  20. 40% showed improvement after treatments • 1/15 worsened pain (Norbrink 2011) • 46% showed improvement • 27% complained of worsening (Nayak 2001) Acupuncture in Chronic Pain

  21. Other Complimentary and Alternative Therapies

  22. 16% improvement in pain with manipulative therapies (Arienti 2011) Osteopathic Manipulative Therapy

  23. Incomplete lesion, used Clinical Biomechanics of Posture protocol (Haas 2005) Chiropractic Care

  24. 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) Manipulative Medicine

  25. “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.)

  26. 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) Visual Illusion

  27. 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) Hypnosis

  28. Does not seem to be helpful in neuropathic pain from SCI (Jensen 2009) Biofeedback

  29. Case reports on 12 and then 7 veterans with SCI (Wardell 2006; Wardell 2008) Healing Touch

  30. Overall does seem to be beneficial in central neuropathic pain (Wade 2003) • Ethically and legally limiting Cannibis

  31. Individual oils / Blends • Topical / Diffused • Types • Numbing: • Anti-inflammatory: • Heat sensation: • Central processing: • Neurotrasmission: • Relaxation: Aromatherapy / Essential Oils

  32. Discussion

  33. 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 Integration

  34. Barriers • With patients • With practitioners • Complimentary approaches • Acupuncture • Massage • Manual therapy • Hypnosis Summary

  35. Questions?

  36. Pannek J, Pannek-Rademacher S, Wöllner J. Use of complementary and alternative medicine in persons with spinal cord injury in Switzerland: a survey study. Spinal Cord. 2015 Jul;53(7):569-72. doi: 10.1038/sc.2015.21. Epub 2015 Feb 24. PubMed PMID: 25708665. • Choi DC, Lee JY, Lim EJ, Baik HH, Oh TH, Yune TY. Inhibition of ROS-induced p38MAPK and ERK activation in microglia by acupuncture relieves neuropathic pain after spinal cord injury in rats. Exp Neurol. 2012 Aug;236(2):268-82. doi: 10.1016/j.expneurol.2012.05.014. Epub 2012 May 23. PubMed PMID: 22634758. • Norrbrink C, Lundeberg T. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study. Acupunct Med. 2011 Jun;29(2):108-15. doi: 10.1136/aim.2010.003269. Epub 2011 Apr 6. PubMed PMID: 21474490. • Dyson-Hudson TA, Kadar P, LaFountaine M, Emmons R, Kirshblum SC, Tulsky D, Komaroff E. Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial. Arch Phys Med Rehabil. 2007 Oct;88(10):1276-83. PubMed PMID: 17908569. • Nayak S, Shiflett SC, Schoenberger NE, Agostinelli S, Kirshblum S, Averill A, Cotter AC. Is acupuncture effective in treating chronic pain after spinal cord injury? Arch Phys Med Rehabil. 2001 Nov;82(11):1578-86. PubMed PMID: 11689979. • Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE, Druin EL. Acupuncture and Trager psychophysical integration in the treatment of wheelchair user's shoulder pain in individuals with spinal cord injury. Arch Phys Med Rehabil. 2001 Aug;82(8):1038-46. PubMed PMID: 11494182 • Boldt I, Eriks-Hoogland I, Brinkhof MW, de Bie R, Joggi D, von Elm E. Non-pharmacological interventions for chronic pain in people with spinal cord injury. Cochrane Database Syst Rev. 2014 Nov 28;11:CD009177. doi: 10.1002/14651858.CD009177.pub2. Review. PubMed PMID: 25432061 • Felix ER. Chronic neuropathic pain in SCI: evaluation and treatment. Phys Med RehabilClin N Am. 2014 Aug;25(3):545-71, viii. doi: 10.1016/j.pmr.2014.04.007. Review. PubMed PMID: 25064788. • Lee JY, Choi DC, Oh TH, Yune TY. Analgesic effect of acupuncture is mediated via inhibition of JNK activation in astrocytes after spinal cord injury. PLoS One. 2013 Sep 9;8(9):e73948. doi: 10.1371/journal.pone.0073948. eCollection 2013. PubMed PMID: 24040124; PubMed Central PMCID: PMC3767587. • Averill A, Cotter AC, Nayak S, Matheis RJ, Shiflett SC. Blood pressure response to acupuncture in a population at risk for autonomic dysreflexia. Arch Phys Med Rehabil. 2000 Nov;81(11):1494-7. PubMed PMID: 11083354. • Nayak S, Matheis RJ, Agostinelli S, Shifleft SC. The use of complementary and alternative therapies for chronic pain following spinal cord injury: a pilot survey. J Spinal Cord Med. 2001 Spring;24(1):54-62. PubMed PMID: 11587436. • Haas JW, Harrison DE, Harrison DD, Bymers B. Conservative treatment of a patient with syringomyelia using chiropractic biophysics protocols. J Manipulative PhysiolTher. 2005 Jul-Aug;28(6):452. PubMed PMID: 16096046. • NorrbrinkBudh C, Lundeberg T. Non-pharmacological pain-relieving therapies in individuals with spinal cord injury: a patient perspective. Complement Ther Med. 2004 Dec;12(4):189-97. PubMed PMID: 15649832. • Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of cervical spinal cord compression: a case series. J Manipulative PhysiolTher. 2006 Mar-Apr;29(3):236-44. PubMed PMID: 16584950. • Kukurin GW. The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation: a case report with long-term follow-up. J Manipulative PhysiolTher. 2004 Jun;27(5):e7. PubMed PMID: 15195045. References

  37. Heo I, Shin BC, Kim YD, Hwang EH, Han CW, Heo KH. Acupuncture for spinal cord injury and its complications: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2013;2013:364216. doi: 10.1155/2013/364216. Epub 2013 Feb 17. PubMed PMID: 23476688; PubMed Central PMCID: PMC3586459. • Lee S, Zhao X, Hatch M, Chun S, Chang E. Central Neuropathic Pain in Spinal Cord Injury. Crit Rev PhysRehabil Med. 2013;25(3-4):159-172. PubMed PMID: 25750485; PubMed Central PMCID: PMC4350234. • Heutink M, Post MW, Wollaars MM, van Asbeck FW. Chronic spinal cord injury pain: pharmacological and non-pharmacological treatments and treatment effectiveness. DisabilRehabil. 2011;33(5):433-40. doi: 10.3109/09638288.2010.498557. Epub 2010 Aug 9. PubMed PMID: 20695788. • FattalC, Kong-A-Siou D, Gilbert C, Ventura M, Albert T. What is the efficacy of physical therapeutics for treating neuropathic pain in spinal cord injury patients? Ann PhysRehabil Med. 2009 Mar;52(2):149-66. doi: 10.1016/j.rehab.2008.12.006. Epub 2009 Feb 14. PubMed PMID: 19909705. • Cardenas DD, Felix ER. Pain after spinal cord injury: a review of classification, treatment approaches, and treatment assessment. PM R. 2009 Dec;1(12):1077-90. doi: 10.1016/j.pmrj.2009.07.002. Epub . Review. PubMed PMID: 19797006. • Kim HY, Wang J, Lee I, Kim HK, Chung K, Chung JM. Electroacupuncture suppresses capsaicin-induced secondary hyperalgesia through an endogenous spinal opioid mechanism. Pain. 2009 Oct;145(3):332-40. doi: 10.1016/j.pain.2009.06.035. Epub 2009 Jul 30. PubMed PMID: 19646817; PubMed Central PMCID: PMC2762198. • DeLisa JA. Developing an integrative approach to spinal cord medicine. J Spinal Cord Med. 2003 Spring;26(1):27. PubMed PMID: 12830965. • Paola FA, Arnold M. Acupuncture and spinal cord medicine. J Spinal Cord Med. 2003 Spring;26(1):12-20. Review. PubMed PMID: 12830963. • Haythornthwaite JA, Wegener S, Benrud-Larson L, Fisher B, Clark M, Dillingham T, Cheng L, DeLateur B. Factors associated with willingness to try different pain treatments for pain after a spinal cord injury. Clin J Pain. 2003 Jan-Feb;19(1):31-8. PubMed PMID: 12514454. • Stoelb BL, Jensen MP, Tackett MJ. Hypnotic analgesia for combat-related spinal cord injury pain: a case study. Am J ClinHypn. 2009 Jan;51(3):273-80. PubMed PMID: 19216212. • Jensen MP, Barber J, Hanley MA, Engel JM, Romano JM, Cardenas DD, Kraft GH, Hoffman AJ, Patterson DR. Long-term outcome of hypnotic-analgesia treatment for chronic pain in persons with disabilities. Int J ClinExpHypn. 2008 Apr;56(2):156-69. doi: 10.1080/00207140701849486. PubMed PMID: 18307126. References

  38. Roosink M, Mercier C. Virtual feedback for motor and pain rehabilitation after spinal cord injury. Spinal Cord. 2014 Dec;52(12):860-6. doi: 10.1038/sc.2014.160. Epub 2014 Sep 30. Review. PubMed PMID: 25266696. • Arienti C, Daccò S, Piccolo I, Redaelli T. Osteopathic manipulative treatment is effective on pain control associated to spinal cord injury. Spinal Cord. 2011 Apr;49(4):515-9. doi: 10.1038/sc.2010.170. Epub 2010 Dec 7. PubMed PMID: 21135862. • Jensen MP, Barber J, Romano JM, Hanley MA, Raichle KA, Molton IR, Engel JM, Osborne TL, Stoelb BL, Cardenas DD, Patterson DR. Effects of self-hypnosis training and EMG biofeedback relaxation training on chronic pain in persons with spinal-cord injury. Int J ClinExpHypn. 2009 Jul;57(3):239-68. doi: 10.1080/00207140902881007. PubMed PMID: 19459087; PubMed Central PMCID: PMC2730649. • Moseley GL. Using visual illusion to reduce at-level neuropathic pain in paraplegia. Pain. 2007 Aug;130(3):294-8. Epub 2007 Mar 1. PubMed PMID: 17335974. • Cardenas DD, Jensen MP. Treatments for chronic pain in persons with spinal cord injury: A survey study. J Spinal Cord Med. 2006;29(2):109-17. PubMed PMID: 16739554; PubMed Central PMCID: PMC1864800. • Carlson MJ, Krahn G. Use of complementary and alternative medicine practitioners by people with physical disabilities: estimates from a National US Survey. DisabilRehabil. 2006 Apr 30;28(8):505-13. PubMed PMID: 16513583. • Panagos A, Jensen M, Cardenas DD. Treatment of myofascial shoulder pain in the spinal cord injured population using static magnetic fields: a case series. J Spinal Cord Med. 2004;27(2):138-42. PubMed PMID: 15162885. • Rapson LM, Wells N, Pepper J, Majid N, Boon H. Acupuncture as a promising treatment for below-level central neuropathic pain: a retrospective study. J Spinal Cord Med. 2003 Spring;26(1):21-6. PubMed PMID: 12830964. • Wade DT, Robson P, House H, Makela P, Aram J. A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms. ClinRehabil. 2003 Feb;17(1):21-9. PubMed PMID: 12617376. • Warms CA, Turner JA, Marshall HM, Cardenas DD. Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful. Clin J Pain. 2002 May-Jun;18(3):154-63. PubMed PMID: 12048417. • Thompson E, Hicks F. Intrathecal baclofen and homeopathy for the treatment of painful muscle spasms associated with malignant spinal cord compression. Palliat Med. 1998 Mar;12(2):119-21. PubMed PMID: 9616449. • Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology. 2014 Feb;120(2):482-503. doi: 10.1097/ALN.0000000000000101. Review. PubMed PMID: 24322588; PubMed Central PMCID: PMC3947586. • Gustin SM, Wrigley PJ, Henderson LA, Siddall PJ. Brain circuitry underlying pain in response to imagined movement in people with spinal cord injury. Pain. 2010 Mar;148(3):438-45. doi: 10.1016/j.pain.2009.12.001. Epub 2010 Jan 25. PubMed PMID: 20092946. • Wardell DW, Rintala D, Tan G. Study descriptions of healing touch with veterans experiencing chronic neuropathic pain from spinal cord injury. Explore (NY). 2008 May-Jun;4(3):187-95. doi: 10.1016/j.explore.2008.02.003. PubMed PMID: 18466849. • Nawoczenski DA, Ritter-Soronen JM, Wilson CM, Howe BA, Ludewig PM. Clinical trial of exercise for shoulder pain in chronic spinal injury. PhysTher. 2006 Dec;86(12):1604-18. PubMed PMID: 17138842. • Wardell DW, Rintala DH, Duan Z, Tan G. A pilot study of healing touch and progressive relaxation for chronic neuropathic pain in persons with spinal cord injury. J Holist Nurs. 2006 Dec;24(4):231-40; discussion 241-4. PubMed PMID: 17098874. References

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