The Pain Practitioner - Migraine, Myofascial Pain and Fibromyalgia

american academy of pain management

Integrative No Life Limited Pain Management

by Pain for Optimal Patient Care

The Pain Practitioner Winter Fall 2015 2013

sorting the symptoms: Fibromyalgia , Chronic Migraine, and Myofascial Pain

​ LSO INSIDE A Mindfulness and SUDs Emotion and Pain Nutrients and Herbals Treat Migraines Stem Cell Therapy for Muscoloskeletal Pain Conditions And More!

American Academy of Pain Management

No Life Limited by Pain

www.aapainmanage.org

ACADEMY BOARD OF DIRECTORS

The Pain Practitioner

President Robert A. Bonakdar, MD, FAAFP Vice President Joanna Katzman, MD, MSPH Past President Alfred V. Anderson, MD, DC Secretary Thomas N. Watson, DPT, MEd Treasurer Jackie S. Rowles, CRNA, MBA, FAAPM Directors-at-Large Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Christian D. González, MD Gerald Q. Greenfield, Jr., MD W. Clay Jackson, MD, DipTh Michael Kurisu, DO, ABIHM Arthur S. Roberts, DDS, MD

FALL 2015, Volume 25, number 3

Notes from the Field

4 What’s the Goal? Relieving Pain, or Relieving Suffering?

By Bob Twillman, PhD, FAPM, Executive Director

Academy News

6 Newly Credentialed Members 10 You Should Know...

Executive Director Emeritus and Director of Board Development Lennie Duensing, MEd

ACADEMY STAFF AND CONSULTANTS

Page 32

Page 41

Page 52

Features

20 Case Studies: Distinguishing Between Fibromyalgia,

Chronic Migraine, and Myofascial Pain

By Joanna Katzman, MD, MSPH

25 Catch and Release: Cognitive Reappraisal as a Mechanism of Action in

Mindfulness-Based Relapse Prevention for Substance Use Disorders

By Bruce F. Singer, PsyD

28 Providing Compassionate Care for People with Pain and Dependency

By Christine Rhodes, MS

32 Understanding and Treating Migraines Using Nutrients and Herbals:

A Focus on Eastern Medicine

By Trupti Gokani, MD

41

Percutaneous Peri-Auricular Peripheral Nerve Field Stimulation:

A Novel Non-Opioid Therapy for Diabetic Neuropathy

By Arthur Roberts DDS, MD, MSc, and Christopher R. Brown DDS, MPS

From the Clinic 48 Autologous Stem Cell Therapy:

A Naturopathic Approach for the Treatment of Chronic

Musculoskeletal Pain Conditions—Part I of II

By Harry Adelson, ND, Tyna Moore, ND, DC, and Paul Anderson, ND

Commentary

52 Location, Location, Location ...

How Emotion Can Relate to Location of Pain

By Jennifer Johnston, PhD, DNM, NMD

Subscribe to The Pain Practitioner!

If you are not a member, you can still get this quarterly publication for just $50/year. Send your check to the American Academy of Pain Management, 975 Morning Star Drive, Ste. A, Sonora, CA 95370

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Executive Director Robert Twillman, PhD, FAPM Director of Education and Credentialing Debra Nelson-Hogan Director of Sales, Marketing and Events Jillian Manley Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Researcher and Policy Analyst Katie Duensing, JD Credentialing Account Manager MacKenzie Davis Website and Database Director Eric Blosch Account Managers Rosemary LeMay, Staci Criswell, and Sheila Miller Accounting Director Kristin Taylor Education Manager Cathleen Coneghen Office Manager Karen Hebert

THE PAIN PRACTItiONER STAFF AND CONSULTANTS Editor-in-Chief Debra Nelson-Hogan Advertising and Sales Jillian Manley, Sheila Miller Managing Editor Cathleen Coneghen Clinical Editor Christine Rhodes, MS Art Director Amy Bothwell Copy Editor Rosemary Hope The Pain Practitioner is published by the American Academy of Pain Management, 975 Morning Star Drive, Ste., A, Sonora, CA 95370, Phone 209-533-9744, Fax 209-533-9750, Email: aapm@ aapainmanage.org, website: www. aapainmanage.org. Copyright 2007 American Academy of Pain Management. All rights reserved. Send correspondance to Debra Nelson-Hogan at dhogan@aapainmanage. org. Contact Sheila Miller at 209-533-9744 regarding advertising opportunities, media kits, and prices.

The Pain Practitioner is published by the American Academy of Pain Management solely for the purpose of education. All rights are reserved by the Academy to accept, reject, or modify any submission for publication. The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of the Academy or individual members. The Academy does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. The American Academy of Pain Management does not assume any responsibility for injury arising from any use or misuse of the printed material contained herein.

The printed material contained herein is assumed to be from reliable sources, and there is no implication that they represent the only, or best, methodologies or procedures for the pain condition discussed. It is incumbent upon the reader to verify the accuracy of any diagnosis and drug dosage information contained herein, and to make modifications as new information arises.

All rights are reserved by the Academy to accept, reject, or modify any advertisement submitted for publication. It is the policy of the Academy to not endorse products. Any advertising herein may not be construed as an endorsement, either expresed or implied, of a product or service.

NOTES FROM THE FIELD

What’s the Goal? Relieving Pain, or Relieving Suffering?

BY ROBERT T WILL M AN, PHD, FAPM, E XECU TI V E DIREC TOR

O

ver the past few months, I’ve been pondering the relationship between the need to manage pain and the need to prevent and treat substance abuse and addiction. Often, we hear these two tasks presented as if they are part of a “zero sum game” that is, anything that successfully improves one problem, worsens the other problem. This view has been part of the pain policy landscape for as long as I can remember, and it has led to the development of enduring theoretical concepts such as the “Principle of Balance”—that we should seek policies that maximize access to opioid analgesics for people who benefit from them, while minimizing that same access for people who misuse, abuse, or divert them. Many battles have been, and continue to be, fought over this concept, but I’m increasingly coming to believe that it misses the point.

I’ve concluded that both the notion that a zero sum game is underway and the Principle of Balance are misstatements of the reality of our work. I believe that these two concepts are valid reflections of the policy environment only when two conditions are true: 1) The only means of relieving pain is opioid analgesics; and 2) The only means of reducing prescription drug abuse is reducing the supply of opioid analgesics. When these two conditions are true, efforts to reduce the supply of opioid analgesics can severely threaten access to those medications, even for people who benefit from their use, and any attempt to improve pain management means that access to opioid analgesics must be increased, thereby threatening to worsen prescription drug abuse.

The good news is that neither of these conditions has to be true. We know, because of the work we do, that there are many means of managing pain besides opioid analgesics.

Increasing access to other pain treatments should actually help reduce the supply of opioids being prescribed, and thus reduce prescription drug abuse—and, voila, we have addressed both problems without adversely impacting either.

Similarly, efforts to address the demand aspects of prescription drug abuse by ramping up primary prevention programs and providing effective treatment for people with the disease of addiction should enable us to reduce prescription drug abuse without limiting supplies of opioid analgesics to such an extent that people with pain are adversely affected. Clinically, we know the ideal solutions are out there—now, we just have to communicate those to policymakers and get them to produce policies that enable us to enact those solutions.

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But, I think there is also something more profound at play here, something that speaks to the philosophy of what we are trying to accomplish when we become clinicians. I’ve witnessed many expressions of extreme bitterness, frustration, anger, and desperation from both people affected by pain and people affected by substance use disorders. In these instances, each group blames the other, in whole or in part, for creating, maintaining, and worsening the problems experienced by the group’s members. There are only rare glimpses of any measure of understanding of, or compassion for, what is being experienced by members of the other group. (And note that those unfortunate enough to be members of both groups are really in trouble, stranded in some kind of “No Man’s Land” between these warring factions.) This lack of empathy is what caused me to consider what it really is that we are trying to accomplish. On the one hand, if our goal really is to relieve or eliminate pain, one way to do that is to keep increasing opioid doses until unconsciousness or death results—in which case, there is no pain. On the other hand, if our goal is to eliminate prescription drug abuse, we can accomplish that by eliminating all prescription drugs—in which case, they aren’t available to be abused or to relieve pain.

To get us out of this conundrum, I think we have to reconsider our goals. If we focus on what I think is a higher goal, we can find compassion for everyone I’ve talked about above, and that frees us to address the problems as we encounter them. That higher goal is this: As clinicians, and perhaps even as human beings, we should always be about relieving suffering, in whatever form we encounter it. Witnessing all the venom between the pain management community and the substance abuse community caused me to realize that we were missing the point—that everyone here is suffering, and more than focusing on relieving pain or reducing substance abuse, we need to focus on relieving suffering. Compassion for people with pain and people with substance use disorders results from recognizing that both are suffering, and when we find that compassion, we can respond by seeking to reduce suffering through the myriad means available to us. To me, that is really what we are called to do as clinicians—and as decent, caring, human beings.

ACADEMY NE WS

Newly Credentialed Members Open to all pain practitioners, the Academy’s Credential demonstrates that a clinician is knowledgeable about interdisciplinary/integrative pain management; has practiced in the field of pain management for at least two years; remains in good standing with federal and state regulatory agencies; has passed a rigorous exam; and is committed to ongoing education in the field of pain. The Academy welcomes the following credentialed pain practitioners who have met the Academy’s requirements and demonstrated proficiency in the management of pain.

Advanced CREDENTIALED PAIN PRACTITIONER (ACPP) Advanced Diplomates Clary Foote, MD, graduated from Dalhou-

sie University with honors and has been in practice for more than 40 years. He is a family medicine practitioner who has worked with people from all walks of life from the Army to inmates in a local prison.

He has always kept his primary care practice open while doing additional work in hospitals and rehabilitation centers.

Dr. Foote has received the Compassionate Doctor Recognition and is very highly thought of by his patients and his community.

Lawrence Roger Lacy, MD, recently led the

Tuscaloosa VA Medical Center in a rapid process improvement workshop for pain management in accordance with safe opioid practices. His advanced certification with AAPM is another testament to his dedication to the safety and effectiveness of multidisciplinary pain management.

Lloyd C. Dyas, MD, was born in London,

England, in 1954. He underwent his medical training in Hamilton, Ontario, Canada. He completed his orthopedic residency at McMaster University in Canada.

He has practiced orthopedic surgery and pain management in Russellville, Alabama, since 1986.

He and his wife Alisha have three children, Chesney, 26, Jordan, 23, and Chandler, 13.

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Bernard R. Wilcosky, MD, graduated from Duke University School of Medicine in 1981. He began his practice of anesthesiology and pain medicine in 1985 after completion of residency at Letterman Army Medical Center. He retired from the Army in 1989 after 24 years of service. Since then he has been in private practice of pain medicine in Redwood City, California.

General Credentialed PAIN PRACTITIONER (GCPP) Diplomates Sally Fisher, MD, MS, is a clinical assis-

tant professor at the University of New Mexico School of Medicine, Department of Internal Medicine, Section on Integrative Medicine, and in private practice in integrative medicine for complex chronic and other conditions including chronic pain. A graduate of Yale University and the University of New Mexico School of Medicine, she is board certified by the American Boards of Preventive Medicine in Occupational and Environmental Medicine, Integrative and Holistic Medicine, and Physician Nutrition Specialists.

Vache Chkamakian, MD, DAAPM, gradu-

ated from USC Medical School and has been a board-certified family physician in Southern California for 29 years. He has worked in a solo practice, county health clinics, Veterans Affairs clinics, community health centers, emergency rooms, urgent care centers, and correctional medicine. He became interested in pain management because of numerous patients in both acute and chronic pain, and is committed to an organized treatment plan and addressing the patient as a whole person.

Larry McCracken, Jr., DC, is the founding

member of Pinnacle Chiropractic Spine and Sports Center in Johnstown, Pennsylvania, where he is currently in private practice. He is a Certified Chiropractic Sports Physician and a Certified Strength and Conditioning Specialist, and for the last 16 years Dr. McCracken has used these skills in private practice as well as a consultant and coach for Richland High School in

ACADEMY NE WS

Thank you to our Corporate Council Members!

®

American Academy of Pain Management CORPORATE COUNCIL MEMBERSHIP Contact Sheila Miller (smiller@aapainmanage.org) or Jillian Manley (jmanley@aapainmanage.org) (209) 533-9744 to become a Corporate Council Member today!

Johnstown. In addition, he is a certified provider of Active Release and Graston Techniques. Always in pursuit of additional ways to help his patients, he became one of only a handful of chiropractors in Pennsylvania to become certified by the McKenzie Institute in Mechanical Diagnosis and Treatment in 2014.

Thank you to our Corporate Members!

ClintonCouncil Daniels, DC, MS, is resident chi-

ropractic physician in the Veterans Affairs St. Louis Health Care System. He has been practicing for five years, specializing in functional rehabilitation, acupuncture, and management of chronic spine conditions.

Dr. Daniels serves on the editorial board for the multidisciplinary journal Topics in Integrative Health Care and the Journal of Clinical Chiropractic Pediatrics. He serves as a team member on the St. Louis VA CARF accredited Interdisciplinary Pain and Rehabilitation Program.® Additionally he is a member of the North American Spine Society and The Society of Federal Health Professionals.

For more information, visit www.aapainmanage.org/ credentialing/, 209-288-2205, email credentialing@ Become acall Corporate Council Memberortoday!

Contact Sheila Miller at smiller@aapainmanage.org, or aapainmanage.org.

Jillian Manley at jmanley@aapainmanage.org (209) 533-9744

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THE PAIN PRACTITIONE R

| VOLUME 25, NUMBER 3 |

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ACADEMY NE WS

INTERVIEW

Insights on Preparing For the ACPP Sanjay Sastry, MD, ADAAPM, recently credentialed as an Advanced Credentialed Pain Practitioner (ACPP), shares his experience with the program with us.

Can you tell us a little about your background?

I am an interventional pain physician practicing in Florida and also am board certified in addiction medicine. My research and publications have been on spinal cord stimulation. I believe that pain is best managed using an integrative approach, which is very much in line with the American Academy of Pain Management’s mission and vision.

Although I was initially trained to believe that nerve blocks or spinal cord stimulation were the best ways to treat pain, I learned after traveling to Europe—especially Germany and the United Kingdom—that interventional pain management is just one of many different approaches to good pain care. Many physicians in Europe use holistic, natural-based medicine and physical medicine to manage pain. I learned about biofeedback, aqua therapy, meditation, and other non-interventional therapies to manage pain. Using these approaches, I saw that patients actually got better and had better pain resolution. I still believe that spinal cord stimulation and other interventional modalities, as well as pharmacologic therapies, have a place in caring for people in pain, but not as a first-line therapy.

Sanjay Sastry, MD, ADAAPM

How would you evaluate the level of difficulty of the ACPP exam?

The ACPP exam was neither easy nor difficult. It was fair.

The exam was extremely expansive, and covered pharmacology, neurology, interventional pain, statistics, psychology, psychiatry, ethics, primary care, physical therapy, and integrative therapies. In order to pass such an exam you need to know the broad spectrum of pain management. Candidates that practice one specialty, such as interventional pain, might be surprised if not properly prepared.

How does the exam compare to similar credentialing exams?

Other exams primarily focus on aspects pertaining to their respective specialty. Neurology certification focuses on neuroscience, neurochemistry, neuroanatomy, headaches, and pharmacological treatments for various pain syndromes. So their exams usually will not ask questions regarding lumbar facet injections or Ayurvedic medications for knee pain. The same is true with other specialty exams. The approach toward the ACPP exam has to start from the top. That means preparation for this exam has to cover a broader array of all aspects of pain.

How does having the ACPP designation help you?

Passing the ACPP exam has its advantages. I feel I have the support of the American Academy of Pain Management. I have confirmed that I have a decent knowledge of integrative pain management. By the way, I also believe that our Canadian colleagues can benefit from this exam.

How did you prepare for the exam?

That is a great question. I prepared by reviewing various journals and text books as recommended by the Curriculum. I also reviewed handouts from the last two years’ Academy Annual Clinical Meetings. The handouts covered a broad aspect of pain management.

What suggestions would you give other candidates on preparing for the exam?

Please review the Curriculum and refer to the references provided. Also, the material presented at the Annual Meeting is good.

Study basic statistics, pain assessment, specific pain conditions, and the range of therapies, particularly pharmacology.

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You Should Know...

The State Pain Policy Advocacy Network (SPPAN) Advocacy results in improved pain policies during 2015 From the moment that legislation is introduced until its passage, and throughout the rule-making processes that implement those laws, the American Academy of Pain Management and SPPAN are constantly evaluating proposed policies and offering feedback in an effort to effect positive pain policies throughout the states. We do this by sending written comments to committees, attending hearings, rallying our network of grassroots advocates, and by reaching out to you, the Academy’s membership of medical experts. We often contact you when an issue needs your urgent attention, so we want to use this month’s issue of The Pain Practitioner to share some examples of how advocacy efforts have improved pain policies across the nation during 2015.

Vermont

Vermont recently released the final version of their Rule Governing the Prescribing of Opioids for Chronic Pain.

In this rule’s original form, it had the potential to harm patient care by requiring that opioid therapy be discontinued in every instance of a treatment agreement violation.

However, current thinking in the medical community is that this provision should indicate that there will be a re-evaluation of the treatment plan, in particular, with respect to controls in place related to medication use, as some people who engage in aberrant drug-related behavior are able to eliminate that behavior if their care is prop-

erly structured (e.g., prescriptions are only provided for a one-week supply at a time). We suggested a change in the language that would allow a re-assessment, institution of controls over medication, tapering, or discontinuation.

Our suggested language was adopted by the final rules, as were our suggestions related to improving policies related to risk assessment tools, morphine equivalent dosage calculators, and the required frequency of urine drug testing.

New Hampshire

New Hampshire, as previously reported, considered a bill which, in its original form, would have defined “dispenser” in such a way that it could have created a chilling effect, preventing some people from receiving appropriate medication for the treatment of acute pain. After receiving our comments, the Senate Health and Human Services Committee amended the bill accordingly. The law that became effective in July was free of any language of concern.

Rhode Island

Rhode Island recently passed a law that requires insurance companies to reimburse any licensed health care practitioner acting within their scope of practice, thus helping to ensure access to affordable integrative health care for Rhode Island’s citizens. Passage of this law, which at one time seemed highly unlikely, came after a concerted show of support from the American Academy of Pain Management, SPPAN, and our partners at the Integrative Health Policy Consortium, The Pain Community, US Pain Foundation, and more.

For a full recap of new laws from 2015 that affect your pain practice, check www.sppan.aapainmanage.org for our annual end-of-session reporting. As always, you can contact SPPAN Director Amy Goldstein at agoldstein@aapainmanage.org to

talk about getting involved with advocacy efforts in your state.

The New Hampshire State House is the nation’s oldest state house, built in 1816-1819.

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Coming this Fall!

The Academy’s All New Online Learning Center The Academy is preparing an online learning management center dedicated to providing education on caring for people in chronic pain.

This new section of our website will contain audiovisual presentations and written educational activities that will be accredited for continuing education. This on-demand system will provide members access to accredited education and allow users to print certificates and access their continuing education history at any time. We are planning to add new programs every month.

Stay tuned for more information.

Streamlined Application Process for the Academy Credential Programs 2015

Academy Credentialing Program KNOWLEDGE CARE COMMUNICATION

The Board of Directors approved a new streamlined process for clinicians who wish to apply for either of the Academy Credentials (the General Credentialed Pain Practitioner or the Advanced Credentialed Pain Practitioner). There are now only 3 items that we ask you to provide: 1) Credentialing application; 2) Copies of all clini-

Academy Contributors Donations to the American Academy of Pain Management (the Academy) support the vital work of the Academy’s policy and advocacy efforts—efforts aimed at ensuring that people with pain have access to the care they need and deserve.

The Academy’s commitment to this work is evidenced by the fact that it is the only pain management organization in the US with a dedicated in-house policy/advocacy team, which is guided by Bob Twillman, PhD—one of the nation’s most respected pain policy leaders. Dr. Twillman carries the Academy’s positions on key issues to policy makers on both the state and federal levels. The Academy’s growing state advocacy efforts are led by Amy Goldstein, MSW, State Pain Policy Advocacy Network (SPPAN) director.

We would like to thank the following contributors for their donations in support of the Academy’s policy and advocacy effort.

Anthony C. Ross, DC, CCSP Anthony D. LaSalle, DDS Bettina T. Limjoco, MD Charles S. Corallo, DC David Firooz, OMD, PT, LAc Douglas A. Friesen, MD Fawzi Fawaz, MD George William Monlux, Jr., MD Gerald Q. Greenfield, Jr., MD Hollis Seunarine, MD I. Antoinette Sutherland, MD, MPH James R. Morris, MD James Uy, MD Jeff L. Buchalter, MD John K. DesMarteau, MD Jordan S. Fersel, MD Linda F. Stone, PhD, RNC, APNP Manjit S. Randhawa, DO

In Memory

Myung Joo M. Cho, MD Nelly K. Mac, MD Pavel Alexandrov, MD Phyllis J. Frostenson, MD Robert Gussenhoven, PharmD Sarah Vlach, MD Steve E Abraham, DPM Syed A. Raoof, MD Thair R. Dieffenbach, PhD Tina Molumphy, MD Vijayalakshmi Balasubramanian, MD William Edward Guptill, MD Zain Vally-Mahomed, MD Donations may be tax deductible as an ordinary business expense. If you would like to donate in support of our policy and advocacy please contact the Academy at 209-533-9744 or aapainmanage.org.

In memory of our deceased members.

John Digregorio, MD Willard L. Mahan, DMD, MA Roy H. Simon, MD

Otto Eisert, MD, PM&R Suvinder Chadha, MD

cal licenses (clear of actions); 3) Curriculum vitae.

The application process is the same for both programs, however, an MD or DO who already holds the GCPP credential needs only to complete the Examination Registration Form in order to register for the ACPP. The General Credentialed Pain Practitioner (GCPP) is a general knowledge test that is open to all clinicians who care for people with pain. The Advanced Credentialed Pain Practitioner Program (ACPP), presently for MDs and DOs only, is designed to allow prescribers to demonstrate a superior level of knowledge, particularly about pharmacology.

For more information, visit www.aapainmanage.org/ credentialing/, call 209-288-2205, or email credentialing@ aapainmanage.org.

This WEEK in pain To find out what happened in pain news this week, check out our new web column.

www.aapainmanage.org/category/ this-week-in-pain/ THE PAIN PRACTITIONE R

| VOLUME 25, NUMBER 3 |

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CASE STUDIES

Distinguishing Between Fibromyalgia ,

Chronic Migraine, and Myofascial Pain

By Joa nna K at zm an, MD, MSPH

Chronic pain syndromes, such as fibromyalgia, chronic migraine, and myofascial pain, can be challenging to diagnose because, while they are all associated with central excitatory mechanisms, their etiology may not be clear. No two of these types of patients are the same so clinicians must be aware of the subtle differences; the diagnosis relies primarily on listening to your patient and getting a thorough history. The following case studies illustrate the most common examination findings and associated symptoms for myofascial pain, chronic migraine, and fibromyalgia.

Case No. 1: Maria

Maria is a 54-year-old Native American woman who has had chronic pain for decades. She complains of pain throughout her body but predominantly feels it in her upper and lower back, neck, arms, and, occasionally, legs. She complains of forgetfulness and difficulty with sleep. She was diagnosed with anxiety and depression 15 years ago, many years after her pain started, and she sees a Native Medicine Healer in her local community for her complaints.

Upon questioning, Maria denies a history of diabetes, polymyalgia rheumatica, or other rheumatoid arthritis.

Inflammatory arthritides such as these are important to rule out in patients with chronic pain. She has no history of migraine headaches or family history of rheumatological disorders. She’s married to her second husband and has four grown children. Maria cannot work due to her chronic pain. She has a history of sexual abuse from one relative during her childhood.

Her current medications are duloxetine 60 mg at night. Her laboratory results are normal and include a chemistry panel, complete blood count, antinuclear antibody (ANA) test, erythrocyte sedimentation rate, and rheumatoid factor test.

Her mental status exam was within normal limits except for some tearfulness and mild difficulties with memory recall. Other basic elements of her memory were within normal limits. Speech, naming, and repetition were all intact, as were her cranial nerves, strength, reflexes, fine finger movements, cerebellar function, and gait. She did have 20

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allodynia, but her responses to primary sensations, such as light touch, pinprick, proprioception, and temperature, were intact. She had pain in 13 out of 18 tender point locations on her musculoskeletal exam.

What is the best diagnosis for Maria: myofascial pain, fibromyalgia, chronic migraine, or somatic symptom disorder?

Many patients like this fit the category of fibromyalgia, but additional information may be needed. Somatic symptom disorder used to be called somatoform disorder, and is characterized by long-term somatic symptoms that are either very distressing or result in significant disruption of functioning. In addition, patients experience thoughts, feelings, or behaviors that are disproportionate to the symptoms themselves.

Why is this not myofascial pain or migraine or somatic symptom disorder? Maria does have pain throughout her body, and she exhibits many characteristics common for fibromyalgia, including depression and anxiety, forgetfulness, and sleep disturbance. In addition, her exam reveals multiple tender points. She has no myofascial trigger points and no other somatic complaints except the tender points.

Wolfe, et al., and the American Academy of Rheumatology identified 18 tender points needed for a clinical diagnosis of fibromyalgia in 1990 (1). Patients needed to exhibit pain in more than 11 of these tender points and have a history of chronic widespread pain lasting at least three months. However, as we know now, tender points are not required for a clinical diagnosis. Newer, symptombased diagnostic criteria include the following risk factors: headaches, from which Maria does suffer; dysmenorrhea, temporomandibular joint dysfunction; chronic fatigue; irritable bowel syndrome; and functional GI disorders.

Fibromyalgia is a chronic and common widespread pain condition characterized by hyperalgesia (heightened sensitivity to pain) and allodynia (pain from a nonnoxious stimulus), sleep disturbance, fatigue, morning stiffness, cognitive complaints, depression, and anxiety (2). Mood disorders, primarily depression, occur in 30% to 50% of patients. Patients with fibromyalgia have an increased

Fibrom yalgia , Chronic Migr aine, and M yofa scial Pain

With chronic pain syndromes, the diagnosis relies on listening to your patient and getting a thorough history.

Fibrom yalgia , Chronic Migr aine, and M yofa scial Pain

lifetime and family history of mood disorders as opposed to patients with rheumatoid arthritis.

Arnold and colleagues concluded from a family study that FM and reduced pressure pain thresholds aggregate in families, and FM coaggregates with major mood disorder in families (3), raising the possibility that genetic factors are involved in the etiology of FM and in pain sensitivity. In addition, mood disorders and FM may share some of these inherited factors (3). However, it is still unclear whether fibromyalgia is entirely genetic, associated with a genetic predisposition, and influenced by environment, particularly stress. There may be one cause or it is multifactorial. Research has identified candidate genes and serotonergic receptor polymorphism phenotypes. Genes for encoding serotonin transporters, dopamine receptors, and catecholamine o-methyl transferases, among others, have also been identified (4,5).

What are the problems in defining fibromyalgia? Fibromyalgia, like depression, migraine, irritable bowel syndrome, and chronic fatigue syndrome are among chronic conditions that lack objective biological markers—yet these symptoms are very real and the conditions are pressing public health problems.

Some of the most efficacious treatments for fibromyalgia are nonpharmacological, but there is an extensive pharmacological armamentarium as well (see Table 1).

First and foremost is education about fibromyalgia and

behavioral treatments such as cognitive behavioral therapy, mindfulness-based stress reduction, and acceptance and commitment therapy; exercise, including gentle exercise, pool therapy, gravity-based exercise, and tai chi. Tricyclic antidepressants and gabapentin are very effective, although they are not FDA approved. Newer, FDA-approved medications include pregabalin, duloxetine, and milnacipran.

Naltrexone in doses of 4.5 mg compounded has also been shown to be effective for fibromyalgia.

Case No. 2: David

David is a 48-year-old Hispanic man with chronic pain in his upper and lower back, shoulders, and buttocks. He has intermittent pain in his proximal lower extremities. He complains of weekly headaches and has been evaluated for surgery on his lumbar spine. His triggers include heavy lifting, sitting for long periods, and driving. His pain is worse upon awakening and with immobility.

He has had five motor vehicle accidents and whiplash. He has a history of diabetes and obesity. He is married with four children, and he’s on temporary disability because of a recent motor vehicle accident that exacerbated his upper and lower back pain. His medications include baclofen 10 mg for muscle spasms, trazodone 50 mg for sleep, and celecoxib 200 mg daily for pain. His previous workups included plain films of his cervical spine that showed straightening of his spine, normal cervical lordosis, and spasticity. An MRI of his lumbar spine showed mild multilevel facet Table 1. Treatment options for chronic pain syndromes arthropathy. His laboratory studies, includFibromyalgia • Education ing CBC, Chemistry 10 panel, ANA test, and • Behavioral treatments: CBT, mindfulness-based stress rheumatoid factor, were all normal. reduction, acceptance and commitment therapy • Support groups His neurological exam was normal, except • Light exercise: pool therapy, tai chi, gravity-based exercise for a pseudoweakness. Detailed strength test• Medications: pregabalin, duloxetine, milnacipran; tricyclic ing showed no true weakness and no muscle antidepressants (not FDA approved) and gabapentin (not FDA approved); naltrexone (not FDA approved) atrophy suggestive of lower motor neuron weakness. Sensory function and gait were Myofascial Pain • Chiropractic or manual therapy intact. The musculoskeletal exam showed mul• Osteopathic therapy and manipulations • Physical therapy tiple trigger points in the muscles of his upper • Trigger point injections and lower back. He had significant spasm in • Acupuncture his paraspinous muscles but no allodynia. He • Light exercise had focal tenderness at the trigger points that • Medications: nonsteroidal anti-inflammatory drugs, muscle were palpated and referred pain with pressure relaxants, topical agents • Myofascial release on several trigger points. He also had some • Stretching limitations in his range of motion, especially • Taper off offending agents Chronic migraine/ after the trigger points were palpated.

Medication • CBT What is the best diagnosis for David? Is it Overuse Headache • Education fibromyalgia, chronic migraine, myofascial • Medications including onabotulinumtoxinA, topiramate pain, or rheumatoid arthritis?

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Fibrom yalgia , Chronic Migr aine, and M yofa scial Pain

Why is this myofascial pain and not fibromyalgia, chronic migraine, or rheumatoid arthritis? David’s predominant pain complaints are located in his upper and lower back, as well as his shoulder girdle. He has reproducible trigger points with referred pain, and he seems to have cervicogenic headaches.

His symptoms are worse with immobility.

We know from migraineurs that, unlike tension headaches, migraines worsen with activity. This patient’s headache was worse with immobility. Fibromyalgia presents with tender points and allodynia. This patient had neither.

And rheumatoid arthritis is associated with positive ANA and rheumatoid factor, among other laboratory findings.

Myofascial pain is characterized by chronic pain from multiple trigger points and fascial constrictions (6). The most common etiology for upper and lower back pain is myofascial pain, and it’s one of the most common causes of disability in the United States today. The most common features of myofascial pain include focal point tenderness, the taut band, the twitch response seen on dry needling or injection with a small amount of lidocaine, referred pain on at least five seconds of continuous pressure over the trigger point, limited range of motion following five seconds of sustained pressure, reproduction of the pain complaint by trigger point palpation, and pseudoweakness. The key is the reproduction of the pain.

According to Janet Travell, MD, a pioneer in the development of myofascial pain treatment, a trigger point is a hyperirritable spot, usually within a taut band of skeletal muscles or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic phenomena.

Treatment options for myofascial pain include chiropractic or manual therapy; osteopathic therapy and manipulations; physical therapy to increase mobility, increase range of motion, correct posture, and decrease spasm; trigger point injections; acupuncture; light exercise; and nonsteroidal antiinflammatory drugs, muscle relaxants, and topical agents (see Table 1).

grandmother also suffered from migraines. She is unmarried and has a 13-year-old daughter who also has headaches. Jane takes topiramate 50 mg twice a day. She uses zolmitriptan as her abortive treatment of choice, and she also uses oxycodone for rescue, which she takes five to seven days per week. Five years ago, she had an MRI of her brain, which was normal.

Her neurological exam is normal. Her motor exam shows full strength, normal sensation, intact cerebellum, and normal gait. The musculoskeletal exam shows trigger points in her trapezius and levator scapulae bilaterally but no trigger points in her low back or limbs. She has decreased range of motion in her neck in flexion, extension, and lateral rotation, and increased pain with axial loading of the cervical spine. She has no tender points.

What is the best diagnosis for Jane? Is it fibromyalgia, myofascial pain, chronic migraine secondary to medication overuse, or anxiety?

Why is this not fibromyalgia, myofascial pain, or anxiety?

Although Jane may have a component of myofascial pain in her upper back, her diagnosis is most consistent with migraine without aura, a primary migraine disorder (from the International Classification for Headaches). She has no cognitive complaints, no sleep issues, and no history of depression, all of which are consistent with fibromyalgia. She could have some anxiety, which is seen in patients with medication overuse and chronic migraine (both secondary causes of migraine).

The International Headache Society classification criteria for chronic migraine include headaches 15 or more times per month for three months or longer that are not attributable to another disorder (7). At least two of the following are needed as well: unilateral location, pulsating quality, moderate to severe intensity; and aggravation by routine physical activity.

In addition, at least one of the following are needed: nausea and/or vomiting, photophobia, and phonophobia.

About 30% of patients experience a visual aura prior to their migraine and will benefit from a nonsteroidal medication taken during this prodrome phase (see Figure 1). This is called

Case No. 3: Jane

Jane is a 42-year-old perimenopausal woman with a complaint of migraine headaches that occur more than 20 times each month. Although the headaches occur almost daily, the use of a specific medication usually relieves the head pain for several hours but not longer than that. Jane has occasional nausea, photophobia and, rarely, vomiting. She also states that her neck and shoulders hurt with her headaches.

She has a history of migraines since puberty but no history of head or neck injury. Her mother and maternal

Figure 1. Phase-Specific Treatment of Migraine Phase II Aura

Phase III Early Headache

Phase IV Late Headache

Phase 1 Prodrome

OTSc, NSAIDs, Non-narcotic Analgesics

Phase V Postdrome

Triptans

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Fibrom yalgia , Chronic Migr aine, and M yofa scial Pain

migraine with aura. Research has shown that migraine patients benefit from triptans taken at the earliest onset of their headache (8). However, the best triptans usually work only 70% of the time. Rescue medications are available for the remaining patients, as long as the patient can take them responsibly.

Jane has chronic migraines possibly exacerbated by medication overuse or rebound. She takes oxycodone and triptans five to seven times weekly.

A recent study reported that topiramate and botulinum toxin were effective for the combination of chronic migraine and medication overuse headaches (9).

Treatment includes tapering off offending agents including opiate and non-opiate analgesics taken on a daily basis. Many patients do very well on chronic daily opiates, but certain patients may suffer from medication overuse headaches. Patients also take excessive amounts of overthe-counter analgesics, as well as triptans. Jane was taking triptans and oxycodone five to seven times per week, so either drug could have been responsible for the overuse headaches.

All three major chronic pain syndromes have many nonpharmacologic and pharmacologic treatment options.

Case No. 4: Esperanza

Esperanza, a 46-year-old, Native American woman, complains of chronic headaches and upper back pain. Her past medical history is significant for dysthymia and anxiety. She lives on a pueblo in northern New Mexico with her grown son. Her medications include diazepam 5 mg twice a day, a muscle relaxant, and oxycodone 5 mg four times a day as needed for pain.

She complains of significant fatigue, unrestorative sleep, and depression. She says she feels sad and has difficulty exercising. The only thing she really can do is cook meals for her son and her granddaughters. She finds that stress exacerbates her symptoms, and to counteract her tremendous fatigue she consumes a great deal of caffeinated beverages.

Her physical exam was unremarkable except for diffuse tenderness to palpation of the large muscle groups of her upper back. She also had allodynia and minimal taut bands suggestive of musculoskeletal spasm.

The diagnosis could easily be fibromyalgia or chronic migraine, but the headaches could be part of a fibromyalgia syndrome or, perhaps less likely, due to myofascial pain. There is definitely depression, probably more than somatoform.

After talking with her more, she admits to having headaches at least 20 times per month. She has constant upper 24

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back pain and a 15-year history of depression and anxiety.

This case illustrates that multiple visits are sometimes needed to get a patient’s complete history. In many instances, it is the psychologist or physical therapist who brings up a history of depression in a patient during a weekly interdisciplinary team conference. Chronic problems such as frequent headaches, upper back pain, and a history of depression and anxiety are often missed during the initial visits.

In Conclusion

If a diagnosis of migraine is considered, it is important to ask the patient about a history of episodic migraine with photophobia, phonophobia, nausea, and vomiting. A diagnosis of fibromyalgia requires serologic testing to rule out treatable causes of arthropaTable 2. Basic Laboratory Testing thies (see Table 2). for the Fibromyalgia Work-up Finally, patients • Antinuclear antibodies (ANA) titer can have multiple • Anticytoplasmic antibodies diagnoses, such as • Serum protein electrophoresis (SPEP) migraine headache • Urine protein electrophoresis (UPEP) and myofascial • Lyme serology pain, as well as • Erythrocyte sedimentation rate (ESR) mental illness along with their chronic pain. It is important to remember that all three major chronic pain syndromes—chronic migraine, fibromyalgia, and myofascial pain—-have many nonpharmacologic as well as pharmacologic treatment options available.

References 1. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62(5):600-610.

2. Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311(15):1547-1555.

3. Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis Rheum. 2004;50(3):944-952.

4. Bondy B, Spaeth M, Offenbaecher M, et al. The T102C polymorphism of the 5-HT2A-receptor gene in fibromyalgia. Neurobiol Dis. 1999;6(5):433­439.

5. Offenbaecher M, Bondy B, de Jonge S, et al. Possible association of fibromyalgia with a polymorphism in the serotonin transporter gene regulatory region. Arthritis Rheum. 1999;42(11):2482-2488.

6. Giamberardino MA, Affaitati G, Fabrizio A, Constantini R. Myofascial pain syndromes and their evaluation. Best Practice Clin Rheumatol. 2011;25(2):185-198.

7. Headache Classification Committee of the International Headache Society (IHS).

The International Classification of Headache Disorders, 3rd edition (beta version).

Cephalalgia. 2013;33(9):629-808.

8. Cady RK, Sheftell F, Lipton RB, et al. Effect of early intervention with sumatriptan on migraine pain: retrospective analyses of data from three clinical trials. Clin Ther.

2000;22(9):1035-1048.

9. Carod-Artal FJ. Tackling chronic migraine: current perspectives. J Pain Res. 2014;7:185-194.

Joanna Katzman, MD, MSPH, an Associate

Professor in Neurology, is the Director of the University of New Mexico Pain Center and Co-director of the UNM Project ECHO Chronic Pain Program in Albuquerque, New Mexico. She is also the Vice President of the American Academy of Pain Management’s Board of Directors.

Catch and Release

Cognitive Reappraisal as a Mechanism of Action in Mindfulness-Based Relapse Prevention for Substance Use Disorders

By Bruce F. Singer , P s y D

Y

ears ago, while working at a chronic pain residential clinic in California, I found myself trying to explain the benefits of a mindfulness meditation practice to a stocky man in his late 30s who had been injured while working as a truck driver for a concrete company. The more I tried to educate Gary (not his real name) on how to use non-judgmental self-acceptance, presence, intention, self-compassion, and gratitude as coping skills, the more he stared at me as if I were speaking Martian.

He was, true to his work, a concrete thinker, and my abstractions were failing him.

“I don’t get it,” he said, “but I’ll think about it.”

And that was how we left it for the day.

Mindfulness, developed by Jon Kabat-Zinn, PhD, and his colleagues at the UMass Medical Center in the late 1970s (1,2) has caught the attention of Fortune 500 CEOs and emerged as viable treatment for everything from chronic pain to depression to personality disorders to substance use disorders (2-5). Surprisingly, few randomized controlled studies have been conducted on mindfulness and relapse prevention for substance use disorders (SUD) over the years, though the pioneering work of the late G. Alan Marlatt, PhD, at the University of Washington is notable for exploring the effectiveness of mindfulness in reducing the frequency and duration of relapses of SUD (6,7).

Recent studies have focused on the mechanisms of actions that may underlie the efficacy of mindfulness-based

SHUTTERSTOCK

Gary said: “When I cast out, I might land a trout. I reel it in and it’s squirming in front of me so I unhook it and toss it back.

That’s called catch and release. And I wonder if that’s what this mindfulness is all about?”

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relapse prevention (MBRP) (8). Current approaches to MBRP utilize manualized and standardized programs such as Eric L. Garland’s Mindfulness-Oriented Recovery Enhancement (MORE). Dr. Garland’s work, which is funded in part from the National Institute on Drug Abuse, has demonstrated effectiveness in limiting relapses through reducing deficits in natural reward processing during chronic pain or drug addiction. In one study, Dr. Garland and his colleagues showed that participants who maintained a mindfulness practice decreased the frequency and duration of relapses beyond treatment as usual (cognitivebehavioral therapy relapse prevention) at one year from initial training (9).

Some researchers have hypothesized that mindfulness enhances distress tolerance through the process of cognitive reappraisal and that this may be the mechanism of action that enhances relapse prevention. This skill, which a meditation practice enhances, is thought to decrease the need to alleviate internal states of discomfort through engagement in impulsive behaviors (10). In helping people to develop meta-cognitive skills to be more “response-able” (to borrow Milton Erickson’s phrase), reactivity to high stress situations may diminish. Witkiewitz and her colleagues also theorize that mindfulness training can increase kindness, self-compassion, and decrease negative self-evaluations or judgment.

Given that there is a growing body of evidence for the efficacy of MBRP, how do we, as clinicians, find effective interventions to motivate individuals who are detoxifying or in early recovery from opiates, benzodiazepines, or alcohol to practice mindfulness on a sustained basis? Experience has shown me that this is no easy matter, especially when the perceived investment of time that is required to develop a consistent and fruitful mindfulness practice is anathema to those individuals who have been conditioned by years of substance use to seek instant gratification for negative physical and emotional states. In previous writings I have discussed a number of metaphors that I use on a regular basis to translate abstract concepts into practical tools (11-13).

If we cast out our consciousness and become hooked to certain thoughts that are easily caught, then the act of unhooking or releasing these thoughts that are dangling right in front of our field of vision becomes the meditation.

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Which brings me back to Gary, the concrete trucker who found himself puzzled and slightly put off by my increasingly frustrated attempts to turn him into a mindfulness meditator.

The day after our conversation, he came into my office with a tentative look in his eye. “I’ve been thinking about everything you told me and I’m wondering if meditation is like when I do catch and release in fly fishing?”

I had to admit I had limited experience with that so I asked him to tell me what he meant.

“Well … when I cast out, I might land a trout. I reel it in and it’s squirming in front of me so I unhook it and toss it back. That’s called catch and release. And I wonder if that’s what this mindfulness is all about.”

It took a moment for the metaphor to filter through my consciousness and then I broke into a big smile and offered up my hand to “high five” him. “That’s exactly what it is,” I said, and I thanked him for teaching me something about mindfulness that I never knew.

Pema Chödrön, an American Buddhist, writes about the concept of shenpa, or becoming hooked to our own thoughts (14). That hook may be the urge to drink, smoke, gamble, overeat, or abuse opiates or other drugs. Thinking of addiction in this sense, we may begin to broaden our definition of it beyond the accepted disease model to one that we might call the dis-ease model. The more we attach ourselves to certain thoughts and feelings, the more we experience a dis-ease of spirit or soul that beckons us to alter our consciousness. The craving for thoughts or hedonic states to be permanent is at odds with the teachings of the Buddha that all states are, essentially, transient in nature.

Shenpa, then, is about our attachment to the desire for things to be different than the way they are. And this, Buddha says, is at the root of all suffering.

From a mindfulness perspective, people do not become addicted to any one particular substance; rather, they become addicted to thoughts that they need a substance to regulate emotional, mental, or physiological states.

Obviously, there are clear physiological consequences to sustained substance use (e.g., chemical dependence), but psychological dependence lasts far beyond post-acute withdrawal and, as most people in long-term recovery with whom I have worked would say, beyond the time when one’s brain has re-regulated neurochemicals such as dopamine and the various endogenous opioid peptides such as endorphin.

If, as Gary taught me, we cast out our consciousness and become hooked to certain thoughts that are easily caught,

MIndfulness - Ba sed Rel apse Pre v en t ion for SUD

then the act of unhooking or releasing these thoughts that are dangling right in front of our field of vision becomes the meditation. What he taught me was that catch and release within a meditation practice is an act of cognitive reappraisal. As practitioners, we can convey to our clients that this is the entirety of the process of mindfulness meditation at the beginning stages of a meditation practice.

Here then, is how we might look at catch and release in a formal breath meditation: We begin, perhaps sitting in a chair or on the floor, with eyes closed and with the intention of paying attention to the breath moving in and out of our bodies. Thich Nhat Hanh, the Vietnamese monk, encourages a kind of silent mantra to be added to this activity that includes a phrase such as “Breathe in peace, breathe out calm.”

It is at this point that most novice meditators get lost in the reeds: They tell themselves that this process is supposed to reduce stress or make pain or cravings go away.

They place a goal on an activity that is, fundamentally, pure process. Mindfulness meditation is not about becoming more relaxed; rather, it is just the act of paying attention to breathing while accepting all thoughts and feelings.

In this sense it is simple but not easy because our discursive minds begin to fight for our attention—like a trout that has been snared. All too often we find ourselves fighting our thoughts and trying to push them out of consciousness. The attempt at avoidance—especially in the face of high-risk situations mediated by impulsive habits— is an impossible task. Mindfulness is not about clearing one’s mind of all thoughts but about accepting that we will always have thoughts—and that we can learn to unhook them, one by one.

So we breathe and reel in a thought—perhaps about the past or future, perhaps a judgment or an urge to use (or to avoid discomfort). As we unhook from the thought or feeling or sensation, it is essential to add gratefulness to the mix. Those thoughts that we have hooked (or that have hooked us) exist only to remind us to return to our focus on breathing. We thank them as we let them go. In this way, our frustration with the nature of mind and with the repetition of this process is, in the language of acceptance and commitment therapy (ACT), defused. Thus this repetitive act of catching and releasing—infused with gratefulness—becomes the meditation and it brings us back, with greater acceptance, to focused attention on the present.

Thus, cognitive reappraisal is a form of meta-cognition: thinking about thinking. Imagine standing in a river and watching the water move past you. It carries twigs and

leaves as fish swim by and logs float past you. You can stand there and risk being swept away … or you can step out, climb up onto the riverbank, and watch the river. This is, as you might sense, a very different experience. Through unattached observation, the skills required for cognitive reappraisal are practiced and the result may be greater distress tolerance.

This is but one mindfulness intervention for relapse prevention, and it worked with Gary. As the advocates for MBRP point out, more work needs to be done on understanding who may benefit from this approach and why. As clinicians, we have to meet our clients where they are and through the mutual process of discovery learn how to work together to meet their goals in recovery.

References

1. Kabat-Zinn J. Coming to Our Senses: Healing Ourselves and the World Through Mindfulness. New York, NY: Hyperion; 2005.

2. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. New York, NY: Dell Publishing; 1990.

3. Zgierska A, Rabago D, Chawla N, et al. Mindfulness meditation for substance use disorders: a systematic review. Subst Abus. 2009;30(4):266-294.

4. Marlatt GA. Buddhist philosophy and the treatment of addictive behavior. Cogn Behav Pract. 2002;9:44-49.

5. Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. New York: Guilford Press; 2002.

6. Hoffman SG, Sayer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: meta-analytic review. J Consult Clin Psychol.

2010;78(2):169-183.

7. Bowen S, Parks GA, Coumar A, et al. Mindfulness meditation in the prevention and treatment of addictive behaviors. In: Nauriyal DK, Drummond M, Lal YB Eds. Buddhist Thought and Applied Psychology: Transcending the Boundaries.

London: Routledge Curzon; 2006.

8. Bowen S, Witkiewitz K, Clifasefi SL, et al. Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry.

2014;71(5):547-556.

9. Garland, EL, Froeliger B, Howard MO. Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RCT. J Behav Med. 2015;38(2):327-336.

10. Witkiewitz K, Bowen S, Harrop EN. et al. Mindfulness-based treatment to prevent addictive behavior relapse: theoretical models and hypothesized mechanisms of change. Subst Use Misuse. 2014;49(5):513-524.

11. Singer BF. A mindful recovery. Addict Professional. 2006;30-35.

12. Singer BF. Transforming fear. Addict Professional. 2009;22-25.

13. Singer JA, Singer BF, Berry M. A meaning-based intervention for addiction: usingnarrative therapy and mindfulness to treat alcohol abuse. In: Routledge C, Hicks J. Eds The Experience of Meaning in Life: Classical Perspectives, Emerging Themes, And Controversies. New York, NY: Springer Press; 2013:379-391.

14. Chödrön, Pema How we get hooked and how we get unhooked. Lion’s Roar: Buddhist Wisdom for Our Time. 2003. http://www.lionsroar.com/how-we-get-hookedshenpa-and-how-we-get-unhooked/#. Accessed June 30, 2015.

Bruce F. Singer, PsyD, is the founding program director of the Chronic

Pain and Recovery Center at Silver Hill Hospital in New Canaan, Connecticut. Licensed as a psychologist in Connecticut, New York, and California, he earned his undergraduate degree from Wesleyan University and both his master’s and doctor of psychology degrees from Pepperdine University’s Graduate School of Education and Psychology in Los Angeles, California. He has authored a number of articles on mindfulness and ACT-based interventions for addiction and pain.

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INTERVIEW

Providing Compassionate Care for People with Pain and Dependency

By Chris tine Rhodes, MS

The Sprintz Center for Pain and Dependency is the first private practice in Texas directed by a physician who is triple board certified in pain medicine, addiction medicine, and anesthesiology. Dr. Sprintz has unique insight, empathy, and understanding of what his most distressed patients are going through. This summer, I spoke with Dr. Sprintz about his approach and what makes him uniquely qualified to help patients struggling with pain and/ or addiction break free and lead Michael Sprintz, DO, happy and productive lives. is Founder and Chief Medical Officer of the Sprintz Center for Pain and Dependency in The Woodlands, Texas. He is the Past President of the Texas Society of Addiction Medicine, and former Medical Director for Memorial Hermann’s PaRC Pain Recovery Inpatient Program.

Describe your typical patient.

My typical patient has chronic low-back and spine pain, or neck pain, neuropathic, and muscular pain. About 15% of my pain patients have active addiction or histories of addictive disease. A few of my addiction patients have no pain issues at all. My patients range in age from 19 to 96 years and mostly come to me from referrals from primary care, neurology, orthopedics, spine surgery, and addiction treatment, as well as from insurance companies. I also get a large number of referrals from my patients.

How would you describe your methods of pain management?

I approach pain management comprehensively. I’m sure we all understand that pain is not just physical; it’s emotional, psychological, spiritual, and energetic. Our psychological makeup, past traumas, family experiences, genetics, and culture all affect how we experience pain as well as our risk to develop addiction. My ideal treatment plan addresses the multifaceted nature of pain, with or without dependency or addiction. The evidence is clear that comprehensive pain programs work. However, getting reimbursement from in28

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surance carriers for such programs is challenging and there are some aspects of our program that may require some out-of-pocket funds.

You state that your goal is to change patients’ relationship with pain. Can you elaborate on this?

Our beliefs create our reality. People in pain often become defined by their pain and restrict their activities because of it. Their world shrinks. Their close relationships become strained. Helping patients see their pain differently— changing their relationship with pain—opens the door to new ideas. Helping patients see that their pain does not define them can be life-changing. Helping patients accept themselves and their current life circumstances can help empower them to begin changing their lives for the better—whether or not “pain” is eliminated. For patients, building healthy coping skills transmits far beyond pain.

Rebuilding self-esteem can help rebuild relationships, ease depression, and consequently, alter patients’ experience of pain and decrease the hobbling impact it has on their lives.

What does it take for someone to switch from just wanting pain relief with medication to taking an active role in his or her pain management?

It takes a change in perspective and beliefs. We live in a society that expects a quick fix and immediate results for many things. Some patients don’t even realize that there are other pain management therapies beside opioids, or they have been told that they “must” be on pain pills the rest of their lives. I always try to help my patients consider the possibility that there are other ways to manage pain besides opioids.

Ultimately, patients must take responsibility for their own wellness and realize that we can work together on managing their pain and improving their health, but I can’t “fix” them.

Shaping realistic expectations is key. I am honest with my patients. I ask them, “How is your life right now? Is it working?

Are you happy?” If it’s not working, then we discuss starting different therapies to begin to move them out of the chronic pain cycle. My goal is to help patients get their pain to the level where they can enjoy life again.

There are certainly patients who want only drugs and

Prov iding Compa ssionate C are for PEOPLE WIT H Pain and Dependenc y

insist that opioids are “the only thing that work,” but most are willing to explore other options. I have many patients say, “I can’t take these meds anymore. They don’t really help but I have pain.” They don’t know what else to do.

I also believe that opioids are a very important tool in our pain management toolbox. They are fantastic medicines when used appropriately in appropriate patients. I do prescribe them and feel strongly that they should remain available for chronic pain patients. The real issue I have is with addiction and lack of training and tools for providers to help identify patients at risk for addiction.

I feel strongly that we need to engage the insurance industry to reimburse for psychological as well as addiction treatment services, especially for patients with co-morbid pain conditions. The long-term benefits, economically, individually, and socially, are significant.

How do you deal with relapses?

Relapse happens. I don’t judge anyone for what they do. At the same time I don’t enable them nor do I avoid discussing the issue with them. I’m very direct with my patients about the issues and risks. I’m here to help patients get better. Relapse is a sign that something they are doing is not working.

I set clear boundaries and am very clear with my patients for their sake as well as mine. In such cases, I would tell patients I will not prescribe opioids because in their specific situation, the risks outweigh the benefits. I don’t discharge them, but work with them to come up with other solutions to help manage their pain. Some patients need inpatient addiction treatment and I refer them to quality treatment programs. My goal is to help patients become accountable and responsible and focused on using other modalities for their pain. In order to help patients deal with their issues, I find it’s most important to build a relationship with them.

I’m also a strong supporter of recovery activities, including 12-step groups, such as AA (Alcoholics Anonymous), NA (Narcotics Anonymous), Chronic Pain Anonymous, and P11 (Pills and prescription drug anonymous). While 12-step recovery groups are the most well known, there are many types of programs and groups that help patients get and stay sober and build a healthy life. I encourage patients to explore the different support groups and programs out there to find one that resonates with them. Chronic pain is isolating, just as addiction is. Finding a group of people who have walked in our patients’ shoes and can help them recover is an amazing gift.

Do you prescribe diet and supplements to your patients?

What do you find particularly helpful?

I don’t sell supplements, but I make recommendations to

patients about a healthy diet, exercise, and supplements.

I find that movement is extremely important in a patient with pain, and encourage patients to get as active as they can at their level of function. I also believe strongly that emotional and psychological wellness and connection with people is vital to managing pain. So, I encourage my patients to engage in therapy, or counseling, as well as actively working on their interpersonal relationships.

Do you recommend meditation or other spiritual practices to your patients?

Absolutely. Engaging in meditation, yoga, energy medicine or energy work, or various other spiritual practices are wonderful in helping to reduce stress and manage chronic pain.

Just as stress has been found to contribute to heart disease, including heart attacks, it can also contribute significantly to chronic pain. Many patients are open to exploring psychological issues, but a lot depends on how we present it to patients. They need to understand that body and mind are connected, and some of their emotional and psychological pain can be expressed as physical pain. I validate that their pain is real, but help them to see how emotional issues and their ability to cope can worsen the pain. Conversely, some patients have horrific pain, but because they have healthy and effective coping skills, they can function and have a wonderful quality of life despite their pain.

What advice do you have for the primary care clinician who treats patients with chronic pain in today’s regulatory climate?

A huge step forward for any clinician who treats patients with chronic pain is to learn more about identifying dependence and substance abuse. We must encourage clinicians to learn about addiction without the expectation that they become addiction specialists. Understanding even the basics will help you know enough to refer someone at risk to a specialist. Opioids are not the only drug being abused— benzodiazepines, carisoprodol, and CNS stimulants to name a few, are routinely prescribed and carry abuse risks, especially in combinations. The biggest mistake practitioners make is not identifying patients with dependence or abuse issues and then unwittingly continue to feed it. The second biggest mistake is not referring patients who need extra help with possible dependence and abuse. Pain patients take on average two-to-three times longer to see than non-pain patients. So, it makes sense from both a patient care and economic standpoint for primary care clinicians to refer pain patients sooner than later to either a pain management clinician or an addiction specialist if they suspect a Continued on page 47

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A FOCUS ON EASTERN MEDICINE

Understanding and Treating Migraines Using Nutrients and Herbals

By T rup t i Gok a ni, MD

M

igraine is more common than asthma and diabetes combined (1), with 36 million sufferers in the United States. Moderate to severe episodes of pain are often associated with nausea and sensitivities to light, sound, and/or smell.

While abortive and preventative medications are available, many seek non-medication approaches such as natural supplements, herbals, and/or homeopathy in hopes of avoiding stronger medications.

As pain practitioners, we must learn integrative approaches so we can advise our patients on the best options for their headaches. In my practice, I find the science of Ayurveda, which is 5,000 years old, to be a unique framework that allows me to offer a more systematic, non-pharmaceutical approach to treat pain.

The basic premise of Ayurveda is that each of us comprises five elements of nature—air, space, fire, earth, and water. These elements create our physiological state and dictate how our mind operates. When considering these elements, it is best to think of the quality of each element to help us understand how we may possess them in our physiological constitution. Air types have the quality of air, which may be light, moving, and mobile. Some of us have a constitution with more air and space elements at birth, thus creating a mind-body, or dosha, type called Vata dosha. Some have a constitution of fire and water elements, thus creating a Pitta dosha type. Others have more earth and water elements thus creating a Kapha dosha type. Your dosha is your nature at birth, and some are combinations, such as Vata-Pitta or Pitta-Kapha. When we live our lives in balance with our nature, symptoms such as pain will not appear.

Eating for your Dosha Type to Balance Headaches

When addressing migraines, it is important to first evaluate the diet and add in foods and certain spices to balance 32

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digestion, which will then balance the mind. In Ayurvedic cooking, foods are often used to ease neurological imbalances among the three doshas and therefore reduce headaches or migraines. Ideally, all Ayurvedic meals should incorporate six tastes: sweet, salty, sour, bitter, astringent, and pungent for good digestion. However, the specific tastes that each person should focus on differ because of what aggravates or pacifies his or her dosha type.

Vata dosha types tend to be built with a smaller frame and have cold, dry skin. They may be restless and are always on the move. When a Vata type has a headache, the pain usually plants itself at the occipital area or base of the skull and throbs. Often, digestive issues such as gas, constipation, and bloating arise with the headache, as well as anxiety and difficulty in focusing. In order to avoid having headaches, Vata patients must avoid light, dry, and crunchy foods, as these can amplify their imbalanced state. Vatas must also try to avoid any cold drinks or frozen foods such as ice cream, and instead drink room temperature or hot drinks and eat warm foods. In general, individuals in the Vata dosha should eat more sweet, salty, and sour foods and limit bitter, astringent, or spicy foods.

While the Vata doshas remind us of wind (cold, dry, and moving), the Pitta doshas resemble fire with their medium build, competitiveness, and tendency to speak directly and to the point. Their headaches form behind the eyes and consist of a sharp, intense pain. In some cases, patients will become nauseous. Therefore, they would have a very different diet to prevent them from experiencing headaches and/or migraines. Overall, those with a Pitta dosha imbalance should avoid hot, sour, and salty foods and acidic beverages because these foods can increase body temperature.

They should also steer away from alcohol, coffee, and soda.

In terms of the six tastes always incorporated in Ayurvedic meals, Pittas tend to fare better with sweet, astringent, and bitter tastes, while they should try to minimize spicy, sour, and salty tastes. One can only imagine how “fired up� a

Under s tanding and Tre ating Migr aines Using Nu trien t s a nd Herbal s

SHUTTERSTOCK

Pitta can become after a cup or two of coffee!

Finally, the Kapha dosha types, typically compared to earth or water, are generally on the heavier side and are more grounded. Since they tend to have trouble with too much mucus forming in their bodies, they need to be careful to not overindulge in certain food groups. Doing so will create a headache with the pain located in the frontal area of their head. While the pain is generally only mild to moderate, it can often come along with congestion, allergies, and weight gain. To avoid this, Kapha dosha types should not consume cold, heavy foods that lead to the creation of mucus, such as ice cream, as well as other dairy products (especially yogurt, cream, and butter) and tropical fruits high in sugar and carbohydrates such as melon and pineapple. Instead, foods that calm the Kapha dosha include bitter, astringent, spicy, warm, dry, and light foods cooked with as little fat as possible.

Whatever one’s dosha, individuals must always listen to

their body. If eating a certain food multiple times causes discomfort or bloating it should be discontinued because it is also likely to throw their dosha type out of balance.

Foods to Avoid

With this eating strategy in mind, it is important to know that there is also a general list of items that all sufferers of migraines should avoid because they can increase the chances of experiencing symptoms. One of these is tyramine, an amino acid that is found in aged and fermented foods, such as aged cheeses, alcohol, processed meats, canned, or pickled foods, citrus fruits, soy products, and even chocolate.

Alcohol is especially harmful to migraine sufferers because it expands blood vessels and increases liver toxicity. Once blood vessels expand, headaches occur, usually within an hour of drinking alcohol.

Additionally, ingredients in packaged foods often cause headaches. Food additives such as nitrates, food coloring, or

Indian gooseberry (Phyllanthus emblica), called aamla in Hindi. It is an essential ingredient of the traditional Indian Ayurvedic medicines.

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Under s ta nding a nd Tre ating Migr aines Using Nu trien t s and Herbal s

MSG (monosodium glutamate) should be avoided as much as possible because they can cause pain on the front or side of the head that is different from migraine symptoms.

Similarly, cold foods such as ice cream lead to “brainfreeze” headaches, the sharp pain in the middle of the forehead that lasts for a few minutes after eating. For some, this can be the start of a migraine that may last up to several hours.

Caffeine can also cause headaches or migraines and should be avoided by patients with chronic headaches to avoid rebound headaches. While caffeine will relieve headache pain for a short time, patients develop a tolerance and withdrawal causes pain starting behind the eyes and moving toward the front of the head. Caffeine can also negatively affect the adrenal glands, interfering with production of a variety of hormones essential to the body’s harmony.

Lastly, dairy products, specifically milk, yogurt, sour cream, and cottage cheese, can cause headaches because of their pro-inflammatory effects. People with allergies to dairy will likely become congested and obtain a pressure headache in their frontal area because of the histamine produced during an allergic reaction.

Supplements to Balance the Brain

With these specific diets in mind, it is also important to note that there are a variety of nutrients that are beneficial to all dosha types. These supplements are well recognized to be helpful for those suffering with headaches.

Omega-3 Fatty Acids. The rationale for the use of omega-3 fatty acids in migraine includes their antiinflammatory properties, vascular relaxation effects, and Table 1. inhibition of seroAyurvedic Herbs for Balancing the Mind tonin release from platelets (2). HowVata Balancing Herbs ever, results of studies • Ashwagandha • Brahmi of their effectiveness • Shankhapushpi in reducing headache • Jatamansi frequency are mixed.

• Haritaki Magnesium.

Pitta Balancing Herbs • Turmeric Deficiencies in mag• Aamla nesium may play an • Black Pepper important role in the • Amalaki • Haritaki pathogenesis of miKapha Balancing Herbs graine headaches by • Tulsi promoting cortical • Guggul spreading depression, • Gurmar • Haritaki alteration of neurotransmitter release, 34

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and hyperaggregation of platelets (3). Studies have shown that oral magnesium may be helpful in migraine prevention (4,5), but doses over 600 mg daily may be needed for a minimum of three to four months to achieve maximum preventative benefits (6).

Vitamin B2. Riboflavin, also known as vitamin B2, is found in small amounts in many foods. It is needed for converting food to energy, and like coenzyme Q10 also works as an antioxidant by mopping up the damaging free radicals. In one study of 55 migraine patients, 59% of the participants who took 400 mg/day of riboflavin for three months experienced at least a 50% reduction in migraine attacks compared with 15% for placebo (7). In another open-label study, the same dose of riboflavin reduced the frequency of attacks and reduced the use of abortive drugs (8).

Niacin. Niacin may have a therapeutic effect on migraine. Although niacin’s mechanisms of action have not been substantiated from controlled clinical trials, this agent may have beneficial effects upon migraine and tensiontype headaches. Adequately designed randomized trials are required to determine its clinical implications (9).

Vitamins B6, B12, and Folic Acid. Some researchers postulate that deficits in mitochondrial energy reserves can cause migraine or an increase in homocysteine levels can lead to migraine attacks. In one study of 52 migraine sufferers, the combination of vitamins B6, B12, and folic acid resulted in fewer attacks and less severe migraines by lowering homocysteine levels (10).

Coenzyme Q10. Coenzyme Q10 is involved in ATP creation and works as an antioxidant. Studies show that supplementation for several months can reduce the average number of days with migraine (11,12).

Alpha-lipoic Acid. Like riboflavin and coenzyme Q10, alpha-lipoic acid is a mitochondrial cofactor directly involved in energy production, while additionally being a potent antioxidant. One study found that daily use for three months was associated with reduced frequency of migraine and a significant decrease in headache severity and headache days (13).

Petadolex (butterbur). Since 1972, this plant has been used to prevent migraines by acting as an antiinflammatory agent, muscle relaxant, and pain reliever. Not only has it been successful in reducing migraines for adults, but it has been shown to be safe and effective in children as well (14-16).

Several Ayurvedic herbs are used to balance the minds of all dosha types: Vata, Pitta, and Kapha. Using these herbs allows patients to have a deeper level of treatment (see Table 1).

Under s tanding and Tre ating Migr aines Using Nu trien t s a nd Herbal s

Summary

By combining traditional Western approaches of medications and injectables with a systems-based model of Ayurveda, we can offer migraineurs another model to help them understand and treat their head pain condition. Using the concept of the dosha, one can understand how migraine patients have become misaligned and take steps to create a more balanced physiology. Utilizing foods and nutrients, this can be done in conjunction with medications to create an optimal mind and body.

References 1. American Migraine Foundation. About Migraine. http://www.americanmigrainefoundation.org/about-migraine. Accessed August 12, 2015.

2. Mann JD, Coeytaux RR. Headache. In: Rakel D. Integrative Medicine. 3rd ed.

Philadelphia, PA: Elsevier Saunders; 2012:91-101.

3. Sun-Edelstein C, Mauskop A. Role of magnesium in the pathogenesis and treatment of migraine. Expert Rev Neurother. 2009;9(3):369-379.

4. Peikert A, Wilimzig C, Kohne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia. 1996;16:257–263.

5. Facchinetti F, Sances G, Borella P, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. 1991;31:298-304.

6. The Migraine Trust. Supplements and Herbs for Migraine—The Evidence. http:// www.migrainetrust.org/factsheet-supplements-and-herbs-for-migraine-theevidence-10897. Accessed August 9, 2015.

7. Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis: A randomized controlled trial. Neurology. 1998; 50: 466-470.

8. Boehnke C, Reuter U, Flach U, et al.High-dose riboflavin treatment is efficacious in migraine prophylaxis: an open study in a tertiary care centre. Eur J Neurol. 2004; 11(7):475-477.

9. Prousky J, Seely G. The treatment of migraines and tension-type headaches with intravenous and oral niacin (nicotinic acid): systematic review of the literature.

Nutrit J. 2005;4:3. doi:10.1186/1475-2891-4-3.

10. Lea R, Colson N, Quinlan S, Macmillan J, Griffiths L. The effects of vitamin supplementation and MTHFR (C677T) genotype on homocysteine-lowering and migraine disability. Pharmacogenet Genomics. 2009 Jun;19(6):422-8.

11. Rozen TD, Oshinsky ML, Gebeline CA, et al. Open label trial of coenzyme Q10 as a migraine preventive. Cephalalgia. 2002;22:137-141.

12. Sandor PS, Di Clemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine. Neurology. 2005;Feb 22; 64(4): 713-715.

13. Magis D, Ambrosini A, Sandor P, et al. A randomized double-blind placebo controlled trial of thioctic acid in migraine prophylaxis. Headache. 2007;47:52-57.

14. Agosti R, Duke RK, Chrubasik JE, Chrubasik S. Effectiveness of Petasites hybridus preparations in the prophylaxis of migraine: a systematic review.

Phytomedicine. 2006 Nov;13(9-10):743-746.

15. Lipton RB, Gobel H, Einhaupl KM, Wilks K, Mauskop A. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology. 2004;63: 2240-2244.

16. Pothmann R, Danesch U. Migraine prevention in children and adolescents: results of an open study with a special butterbur root extract. Headache.

2005;45:196-203.

Trupti Gokani, MD, is an award-winning, board-

certified neurologist best known for her innovative and integrative approach to treating headache pain.

Dr. Gokani is the founder of the North Shore Headache Clinic and the Zira Mind and Body Center in Chicago, Illinois. Dr. Gokani is the author of The Mysterious Mind: How to Use Ancient Wisdom and Modern Science to Heal Your Headaches and Reclaim Your Health, available on Amazon.com.

Contributions to the article also made by Nina Leutz.

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THE PA IN PRACTITIONE R

| VOLUME 25, NUMBER 3 |

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Percutaneous Peri-Auricular Peripheral Nerve Field Stimulation A novel, Non-Opioid therapy for diabetic neuropathy Arthur Robert s DDS, MD, MSc , and Chris topher R . Brown DDS, MPS

N

SHUTTERSTOCK / AGSANDREW

europathy has a complex pathogenesis, and can affect sensory, motor, and autonomic nervous systems in a number of different ways.

Diabetic neuropathy results in complications involving the sensory, motor, and autonomic systems.

These changes have long been understood to be associated with altered perfusion and metabolic function (1,2).

Vagal stimulation alters perfusion. Perfusion alters neuropathy. Therefore, vagal stimulation alters neuropathy. This simple syllogism provides a basis to consider vagal neuromodulation as a potential adjunct therapy for patients with neuropathy in general, and symptomatic

diabetic neuropathy in particular (3).

Methods and Materials

During June, July, and August 2014, in three separate Midwest centers, a cohort of 20 patients experiencing unremitting multiyear chronic pain underwent a series of four one-week peri-auricular percutaneous peripheral nerve field stimulation (PENFS) treatments. Subject patients were selected sequentially.

To be included in the study, patients had to have consistent, daily pain (greater than 4 on the Visual Analog Score [VAS] for 30 days in a row) and no on-demand implantable electrical devices. The skin of the ear at the site of the Neuro-Stim System implantation had to be intact and free of infection. In addition, the participants’ vital signs (HR/breathing/blood pressure) had to be within stable acceptable medical limits. Participants could have no history of seizures, not be pregnant, and be willing to participate and understand/sign the patient consent.

Patients were excluded from the study if they had intermittent, non-daily pain, did not have at least one external ear, and had broken or infected skin at the external ear site.

Patients were also excluded if they had inconsistent vital signs (fluctuating, extremely low blood pressure, or tachycardia), wore any type of implanted electrical device such as a brain shunt, vagal stimulator, pace maker, or spinal pain pump, had a history of seizures, were pregnant, had hemophilia or psoriasis vulgaris, or were unwilling to voluntarily participate. The device used for the percutaneous peripheral nerve field stimulation was the Neuro-Stim

Vagal stimulation alters perfusion.

Perfusion alters neuropathy.

Therefore, vagal stimulation alters neuropathy.

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Percu taneous Peri - Auricul ar Peripher al Nerv e Field St imul at ion

Dorsal Upper Third

Figure 1: NSS as received from manufacturer

Dorsal Middle Third

1. Great Auricular Nerve 2. Lesser Occipital Nerve* 3. Auricular Branch of Vagus Nerve 4. Auriculotemporal Nerve

System (NSS©) (Figure 1) manufactured by Key Electronics, Jeffersonville, Indiana.

The NSS kit consists of the following: 1. An EAD (External Auricular Device), which is an FDAapproved neuromodulating generator targeting acute and chronic pain with a frequency of 1-10 Hz, pulse width of 1 ms, amplitude of 3.2 v, impulse of 100 mw, and interval of 2 sec. The length of stimulation was 120 hours, given in a cycle of 2 hours on/2 hours off.

2. A wire harness, consisting of three 4-pin arrays and one single pin ground wire connected by wire leads to a connector that attaches to the generator.

3. A transilluminater designed to help visualize and isolate targeted neurovascular bundles.

4. Tweezers.

5. Steri-Strip© liquid adhesive to help adhere the electrode arrays and single pin ground wire to the skin to help assure proper energy transfer.

6. A surgical marking pen.

7. Oval bandages to help hold the arrays and ground pin in place.

8. Tegaderm™ bandages to help affix the wires (if needed).

9. Alcohol pad to disinfect the skin at the implantation sites.

The EAD generator is approved for use in a targeted population of acute and chronic pain patients. The device is designed to stimulate the neurovascular bundles of peripheral branches of the cranial nerves found in the peri-auricular area (external ear) including the vagus (X), trigeminal (V), facial (VII), hypoglossal (XI), and occipital nerves and branches of the posterior auricular and superficial temporal arteries (Figure 2).

were recorded by the patient using the VAS pain scale.

Patients were placed in a supine position, and observing sterile technique the peri-auricular area was cleansed with a 70% solution of isopropyl alcohol. The area was evaluated by IHS’s (Innovative Health Solutions) patent pending technique of transillumination to visualize and isolate the neurovascular bundles associated with the terminal afferent branches of the targeted cranial neurovascular nerve bundles. The targeted areas were marked with a provided surgical pen on the ventral and dorsal sides.

Steri-Strip© liquid adhesive was placed over the marked areas (4). The percutaneous electrodes were then implanted within 1 mm of the previously identified neurovascular bundles and secured with the provided oval bandages. The electrode harness was inserted into the solid-state integrated circuit generator. The generator with connected harness was attached behind the ear with double-sided surgical tape by removing the tape backing and pressing firmly onto the skin for 15 seconds (Figure 3).

The patients remained supine and were observed for an additional 30 minutes, being evaluated for any adverse reactions. At the end of that time, VAS scores were again collected and recorded as per protocol.

Procedure

Results

Vital signs were recorded, and pre-treatment pain levels

Six men and 14 women, with an average age of 60.1 years

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*Communication with Vll, lX, GON

Dorsal Lower Third

Figure 2: Cranial Nerve Distribution in Ear

Percu ta neous Peri - Auricul ar Peripher al Nerv e Field St imul at ion

(range 29 to 81 years) participated in the study.

Their average starting VAS was 7.6 and their average ending VAS was 2.65. The average reduction in VAS score was 4.95, which represented an improvement of 65% (see Table 1).

Adverse Reactions Overall, 1% to 5% of paFigure 3: tients experienced discomNSS in place on patient fort upon insertion of the electrodes for less than five minutes, and experienced a drop in blood pressure. Other adverse reactions were conceivable; however, no patients experienced discomfort at the lead placement site for more than five minutes, bleeding at the electrode site from penetration of the neurovascular bundle, localized discomfort due to dislodgement of the electrodes during the wearing of the device, localized dermatitis, syncope, or skin piercing with percutaneous needles.

Discussion

Woolf, Wallace, Clauw, Melzack, and many others have repeatedly demonstrated the association of chronic pain conditions with central sensitization, autonomic dysfunction, disturbances in serotonin function, decreases in endogenous opioid production, and persistent inflammation of microglia. In addition, neuropsychiatric dysfunction is a common comorbid presentation in these patients. In this complex and integrated milieu, we are left to evaluate subjective pain and function levels as a measure of our outcomes (5-25). Recognizing full well the significant impact on the neuromatrix of the factors above, and multiple others, we have set out to measure changes in VAS scores subsequent to the placement of a series of percutaneous peripheral nerve field stimulators.

The clinical application and efficacy of percutaneous electrical neural stimulation (PENS) has been accepted throughout the physician community, has been verified for use in many acute and chronic pain conditions, and also has been reported as a complementary therapy for the management of pain secondary to bony metastasis.

This procedure is distinguished from manual acupuncture, electrical acupuncture, and TENS although the physiological results may be similar. As opposed to acupuncture, the location of PENS needles is determined by neurological

Table 1.

Change in VAS Scores Following Peripheral Nerve Stimulation Average Age 60.1

Total VAS

Pre Post 152 53

Cohort average initial VAS

7.6

Cohort average final VAS

2.65

Cohort average VAS improvement

4.95

Cohort average % VAS improvement 65 F>M 14/6 F average initial VAS

7.92

F average final VAS

2.78

F average % improvement

64.89

M average initial VAS

7.16

M average final VAS

2.33

M average % improvement

67.45

and vascular proximity rather than theories of energy flow or reflex points. Percutaneous electrical neural stimulation therefore provides indirect stimulation to the nerves via a battery-operated pulse generator which delivers current that can be varied in form, intensity, frequency, and is differentiated from the use of fine needles inserted through the skin to stimulate peripheral sensory nerves.

The reduction in symptoms of systemic disorders such as fibromyalgia, knee pain, lower back pain, inflammation, and edema/ischemia is thought to be from the effect on the mid brain, endorphin production, and stimulation of spinal and peripheral inhibitory pain mechanisms via direct neurovascular stimulation and reduction of sympathetic fibers in the arterial walls. The NSS neurostimulation system allows for direct, physician-applied, evidence-based, ambulatory, continual treatment.

The use of electrical stimulation has been indicated for reducing the need for analgesic drugs such as NSAIDS, and central-acting opioids (26). This may also help alleviate the dependencies, addictions, and other common complications found with opioid use such as immunosuppression, constipation, and hyperalgesia (27-29). Reduction of pain and the reduced use of opioids may reduce the length of postoperative hospital stays and therefore should be explored for reducing the incidence of hospital acquired infections (27,30).

Studies have shown that peripheral electrical neural THE PA IN PRACTITIONE R

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Percu taneous Peri - Auricul ar Peripher al Nerv e Field St imul at ion

stimulation resulted in a reduction in VAS and other pain scores compared to sham needle placement and placebo in tension, migraine, and post traumatic headache (31), a decrease in the frequency of sciatica pain (32), and a decrease in diabetic neuropathic pain. In addition to decreasing extremity pain in patients with diabetic neuropathy, PENS therapy improved physical activity, sense of well-being, and quality of sleep while reducing the need for oral nonopioid analgesic medication (33).

The NSS is the first device specifically designed to provide ambulatory, percutaneous neuromodulating nerve field stimulation in the peri-auricular area utilizing the technique and concept of visualizing and targeting auricular neurovascular bundles. The 120-hour treatment (in two hour cycles) helps provide neurovascular stimulation over a much extended time compared to other PENFS techniques.

All participants of the study reported use of prescribed central-acting opioids throughout their course of treatment and none reported satisfactory resolution of their pain. Long term efficacy of opioids in the control of chronic non-cancer pain should be approached cautiously by both user and prescribers. FDA REMs guidelines have been established for

non-invasive

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non-drug treatment for chronic & acute pain…

Manufacturer Authorized Direct Purchase - Full “Peer to Peer” (P2P) Support - Streamlined On-line Credentialing is a percutaneously placed microchip-controlled pulsed neurotransmitter.

It provides a continuous flow of intermittent, low frequency electrical pulses to specific peripheral and vagal nerves.

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Pulse Stimulation Treatment (PSTIM™) is an FDA approved treatment program.

44

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evaluating the use of extended release and long acting opioids often used for the treatment of chronic pain (34).

The patient population for this clinical report of findings was not controlled for any specific pain entity but rather was included into the study based upon the inclusion and exclusion criteria as outlined—specifically daily, consistent pain. Multiple participants in our study were experiencing complications of diabetic neuropathy. Their response to treatment was consistent with the cohort as a whole. We have not dealt directly with the metabolic pathways of neuropathy in this report, but suffice it to say that metabolic pathways are highly dependent on autonomic nervous system function.

Of further significance was the lack of any unacceptable clinical complications such as dermatitis, infections, bleeding at the site of implantation, or syncope at any of the three clinical sites. There were also no reports of injury (skin piercing) or otherwise of any of the participating clinicians. This presents a strong indication of clinical safety. The FDA clearance for the device has been placed in the “minimal risk” category and is further substantiated by this clinical report of findings.

Conclusion

Initial clinical reports of findings at three independent sites indicate that the use of Neuro-Stim System (NSS) peri-auricular percutaneous electrical nerve field stimulation (PENFS) appears to be an effective, minimal-risk, non-narcotic alternative for reducing chronic pain. While further double-blind and long-term studies are needed, the initial findings indicate a significant reduction in patient reported pain. Because of the efficacy and minimal risk, the Neuro-Stim System (periauricular PENFS) should be considered by clinicians as a non-narcotic adjunct for chronic pain control.

References 1. Stevens MJ, Feldman EL, Greene DA. The aetiology of diabetic neuropathy: the combined roles of metabolic and vascular defects. Diabet Med. 1995;12(7):566579.

2. Cameron NE, Cotter MA. Metabolic and vascular factors in the pathogenesis of diabetic neuropathy. Diabetes. 1997;46(Supp 2):31-37.

3. Frangos E, Ellrich J, Komisaruk BR. Non-invasive access to the vagus nerve central projections via electrical stimulation of the external ear: fMRI evidence in humans. Brain Stimul. 2015 May-Jun;8(3):624-36.

4. Peuker ET, Filler TJ. The nerve supply of the human auricle. Clin Anat. 2002; 15:35-37.

5. Doubell TP, Mannion RJ, Woolf CJ. The dorsal horn: state dependent sensory processing, plasticity and the generation of pain. In: Wall PD, Melzach. Eds. Textbook of Pain. 4th ed. Edinburgh: Churchill Livingstone; 1999:165-181.

6. Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespresd pain in patients with fibromyalgia and chronic fatigue syndrome.

Clin Rheum. 2007;26(4):465-473.

7. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ.

2001;65(12):1378-82.

8. Woolf CJ. Central sensitization. In: Basbaum A. Ed. Pain and the Control of Pain: Pain Transmission, Regulation and Management. The Biomedical and Life Sciences Collection. London: Henry Stewart Talks Ltd; 2009.

9. Woolf CJ. Dissecting out mechanisms responsible for peripheral neuropathic pain: Implications for diagnosis and therapy. Life Sci. 2004;74(2605-2610.

Percutaneous Peri-Auricular Peripheral Nerve Field Stimulation

Continued from previous page

Continued from page 30

10. Wallace DJ, Clauw DJ. Eds. Fibromyalgia and Other Central Pain Syndromes.

Philadelphia: Lippincott Williams & Wilkins; 2005.

11. Bartsch T, Paemeleire K, Goadsby PJ. Neurostimulation approaches to primary headache disorders. Curr Opin Neurol. 2009;22(3): 262-268.

12. Goadsby PJ. Migraine pathophysiology. Headache. 2005;45 Suppl(1):S14-24.

13. Goadsby PJ. Neurostimulation in primary headache syndromes. Exp Rev Neurother. 2007;7(12): 1785-1789.

14. Goadsby PJ, Cohen AS, Matharu MS. Trigeminal autonomic cephalgias: diagnosis and treatment. Curr Neurol Neurosci Rep. 2007;7(2): 117-125.

15. Saper JR, Dodick DW, Silberstein SD, et al. Occipital nerve stimulation for the treatment of intractable chronic migraine headache: ONSTIM feasibility study.

Cephalalgia. 2011 Feb;31(3):271-85.

16. Zhuo M, Sengupta JN, Gebhart GF. Biphasic modulation of spinal visceral nociceptive transmission from the rostroventral medial medulla in the rat. J Neurophysiol. 2002 May;87(5):2225-36.

17. Wei F, Dubner R, Zou S et al. Molecular depletion of descending serotonin unmasks its novel facilitory role in the development of persistent pain. J Neurosci.

2010;30(25): 8624-8636.

18. Thalakoti S, Patil VV, Damodaram S. et al. Neuron-glia signaling in trigeminal ganglion: implications for migraine pathology. Headache. 2007;47(7): 1008-1023.

19. Nijs J, Malfliet A, Ickmans K, et al. Treatment of central sensitization in patients with ‘unexplained’ chronic pain: an update. Expert Opin Pharmacother. 2014 Aug;15(12):1671-83.

20. Dorr AE, Debonnel G. Effect of vagus nerve stimulation on serotonergic and noradrenergic transmission. J Pharmcol Exp Ther. 2006;318(2): 890-896.

21. Engineer ND, Riley JR, Seale JD, et al. Reversing pathological neural activity using targeted plasticity. Nature. 2011 Feb 3;470(7332):101-4.

22. Schlaepfer TE, Frick C, Zobel A, et al. Vagus nerve stimulation for depression: efficacy and safety in a European study. Psychol Med. 2008;38(5): 651-661.

23. You H-J, Lei J, Sui M-Y, et al. Endogenous descending modulation: Spatiotemporal effect of dynamic imbalance between descending facilitation and inhibition of nociception. J Physiol. 2010;(Pt 21): 4177-4188.

24. Zhang Y, Popovic ZB, Bibevesky S, et al. Chronic vagus stimulation improves autonomic control and attenuates systemic inflammation and heart failure progression in a canine high-rate pacing model. Circ Heart Fail. 2009;2(6): 692-699.

25. Roberts AS. Central sensitization: clinical implications for chronic head and neck pain. Clin Med Diagn. 2011. 1(1): p. 1-7.

26. He W, Wang X, Shi H, et al. Auricular acupuncture and vagal regulation. Evid Based Complement Alternat Med. 2012;2012:78683.

27. Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials. Pain.

2007;130(1-2): 157-165.

28. Hay JL, White JM, Bochner F, et al. Hyperalgesia in opioid- managed chronic pain opioid- dependent patients. J Pain. 2009;10(3):316-22.

29. Wei G, Moss J, Yuan CS. Opioid induced immunosuppression: is it centrally mediated or peripherally mediated? Biochem Pharmacol. 2003;65(11):1761-1766.

30. Rubin RJ, Harrington CA, Poon A, et al. The economic impact of Staphylococcus aureus infection in New York City hospitals. Emerg Infect Dis. 1999 JanFeb;5(1):9-17.

31. Ghoname EA, Craig WF, White PF Use of percutaneous electrical nerve stimulation (PENS) for treating ECT-induced headaches. Headache. 1999;39(7): 502-05.

32. Ghoname EA, White PF, Ahmed HE, et al. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica.

Pain. 1999;83(2): 193-199.

33. Hamza MA,White PF, Craig WF, et al. Percutaneous electrical nerve stimulation: a novel therapy for diabetic neuropathic pain. Diabetes Care. 2000;23(3):365-370.

34. FDA. Risk evaluation and mitigation strategy (REMs) for extended release and long acting opioids. 2014.

Providing Compassionate Care for People with Pain and Dependency

Arthur Roberts DDS, MD, MSc, is Adjunct Clinical Assistant Professor in the Department of Oral Pathology, Medicine, and Radiology, Indiana University School of Dentistry, Indianapolis; and is adjunct faculty in the Department of Anaesthesia, Critical Care, and Pain Medicine, University of Edinburgh, UK. Christopher R. Brown, DDS, MPS, currently serves as the director of research and development for Innovative Health Solutions, works with the Henry Jackson Foundation and the Defense and Veteran’s Center for Integrative Pain Management developing clinical for Peri-auricular PENFS, and is in private practice in Versailles, Indiana.

dependence or abuse issue.

In my practice, I rely on certain tools to assess what patients are doing out of the office. Even before the office visit, I check my state’s prescription drug monitoring program (PDMP) database for information on that patient. I order urine drug testing and I use the results to help me make more informed decisions and provide better care to my patients.

Screening tools give a quick and dirty assessment, and a good history is essential. These tools are extremely useful for starting the discussion with patients and I strongly encourage using them. There can be significant medico-legal risk by not checking the state PDMP before prescribing a controlled substance and a medication-related incident occurs.

How has your personal experience with addiction influenced your work?

I’ve been sober from drugs and alcohol for over 14 years.

I had a problem with addiction and crashed at the end of my second year of my anesthesiology residency. After several years in active recovery, I was able to complete my residency and went on to become board-certified in anesthesiology as well as addiction medicine. At my hospital I often became the anesthesiologist who took care of patients with addiction issues or chronic pain undergoing surgery.

Finally, I went back for a pain medicine fellowship and over time learned that most pain physicians don’t understand enough about addiction and most addiction physicians don’t understand enough about chronic pain.

I’m very clear that this is what I’m supposed to do in life. In the process of getting sober, I learned how to be direct and honest in a loving way. I have empathy with my patients and I share my experience with them when appropriate. My experience helps me identify patients with issues and have conversations with authenticity. I’ve learned that addiction is a progressive disease. Many individuals never had an issue with substance abuse previously, but had a pain issue and became hooked on opioids.

You don’t have to be in recovery or an addiction specialist to help your patients. While there are some patients that are not yet ready to deal with their dependency or addiction, the vast majority of patients just want to get better and they are looking to us to help them.

Christine Rhodes, MS, is Clinical Editor of The Pain Practitioner.

Figure 1 and 3 photos contributed by Mark Volz, BS.

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Autologous Stem Cell Therapy A Naturopathic Approach for the Treatment of Chronic Musculoskeletal Pain Conditions—Part l of ll An emerging approach to the treatment of chronic musculoskeletal pain is the harvest and concentration/isolation of autologous mesenchymal stem cells (MSCs) for reinjection into damaged or degenerated joints, ligaments, tendons, and muscles. MSCs have been dubbed “patient-specific drug stores for injured tissues” because of their ability to secrete bioactive factors and signals at variable concentrations in response to local microenvironmental cues (1).

MSCs are found throughout the body in many tissue types, but they are particularly abundant and easily harvested from the medullary cavity of flat bones and from adipose tissue (2,3). MSCs can be easily concentrated from bone marrow with simple centrifugation. With a little more effort, MSCs can be isolated from adipose tissue through a multistep process of incubation/enzymatic digestion with collagenase

Colored scanning electron micrograph (SEM) of a human mesenchymal stem cell (MSC)

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followed by centrifugation and filtration. When injected into the site of damage or degeneration, MSCs release a spectrum of antiinflammatory, immunomodulatory, and trophic factors that trigger the regeneration and healing of connective tissues through activation of stem cells endogenous to the site.

As the pool of data continues to grow, the site-specific injection of autologous stem cells has shown promise in musculoskeletal pain conditions such as osteoarthritis (4), sports/traumatic injury (5), low back and discogenic pain (6), neck pain with or without cervicogenic headaches (7), and osteonecrosis (8). Of note, concurrent bodies of data continue to grow that appear to refute the validity of arthroscopic surgery for knee pain (9) and cast doubt upon the validity of steroid epidurals for low back pain (10,11).

Naturopathic physicians in the U.S. and Canada have a rich history of performing prolotherapy, introduced to the profession first and foremost by the deceased Rick Marinelli, ND, past president of The American Academy of Pain Management. The injection of autologous stem cells for the treatment of chronic musculoskeletal pain can be viewed as the natural evolution of prolotherapy, and its proposed mechanism of action, namely the regeneration of damaged or degenerated tissues through triggering the body’s own healing response, is perfectly aligned with the guiding principles of naturopathic medicine (see Table 1).

This article is part I of a twopart series on the naturopathic approach to the use of autologous stem cells for the treatment of chronic musculoskeletal pain conditions. Part I examines the laying

Steve Gschmeissner / Science SourCE

Harry Adelson, ND, T yna Moore, ND, DC, and Paul Anderson, NMD

FROM THE CLINIC

Table 1 The Guiding Principles of Naturopathic Medicine (12) • The healing power of nature (vis medicatrix naturae): Naturopathic medicine recognizes an inherent self-healing process in people that is ordered and intelligent. Naturopathic physicians act to identify and remove obstacles to healing and recovery, and to facilitate and augment this inherent self-healing process.

medicine to improve outcomes with regenerative and stem cell therapies as well as to contribute to the health and wellbeing of society as a whole.

Exercise

Naturopathic physicians subscribe to the belief that exercise may be the single most powerful tool for health and longevity (17) and exercise should always • First do no harm (primum non nocere): Naturopathic physicians follow three be the first prescription (18). From guidelines to avoid harming the patient: —Use methods and medicinal substances that minimize the risk of harmful increasing mitochondrial output as well side effects, using the least force necessary to diagnose and treat as synthesis of new mitochondria, to —Avoid when possible the harmful suppression of symptoms improving blood sugar regulation and —Acknowledge, respect, and work with individuals’ self-healing process insulin sensitivity, regular exercise pro• Doctor as teacher (docere): Naturopathic physicians educate their patients vides broad-reaching benefits to cellular and encourage self-responsibility for health. They also recognize and employ the therapeutic potential of the doctor-patient relationship. metabolism (19).

• Treat the whole person (tolle totum): Naturopathic physicians treat each Exercise triggers an increase in patient by taking into account individual physical, mental, emotional, genetic, mitochondrial biogenesis through the environmental, social, and other factors. Since total health also includes spiritual stimulation of AMP-activated prohealth, naturopathic physicians encourage individuals to pursue their personal spiritual development. tein kinase (AMPK) (20). Moreover, • Prevention (praevenire): Naturopathic physicians emphasize the prevention of exercise has been shown to reverse the disease by assessing risk factors, heredity, and susceptibility to disease, and by inhibition of neural stem cells caused making appropriate interventions in partnership with their patients to prevent illness. by alcohol consumption (21). The effects of strength training on increasing human growth hormone and testosterone levels are well known. In addition, movement and exercise are thought to be beneficial after of a foundation of optimal cellular metabolism, connective stem cell therapy as they promote and improve collagen tissue health, and overall function of the human organism synthesis during the remodeling phase (22). through non-invasive and natural modalities that are not exclusive to naturopathic medicine: diet, exercise, hormone optimization, nutritional/botanical supplements, and intra- Hormone Optimization Hormones affect nearly every cellular process in the huvenous micronutrient therapy. man organism and bio-identical hormone optimization is a major cornerstone of naturopathic training and practice. As Nutrition such, naturopathic physicians consider the impact hormonAccording to naturopathic doctrine, a diet consisting of a al imbalances may have on clinical outcomes with every variety of whole foods, adequate protein, healthy fats, and patient and, certainly when providing stem cell therapies nutrient-dense vegetables and leafy greens, in conjunction the optimization of the anabolic hormone, testosterone, with stem cell therapy, can only serve to improve outcomes and the metabolic hormone, thyroid, is important.

(13,14). Protein is essential for proper bone development Testosterone is anabolic and as such promotes tissue and remodeling as well as collagen deposition. Vitamin C deposition and growth. Testosterone has been used as a from food sources is critical in collagen synthesis. site-specific percutaneous injection to stimulate target Glucose intolerance hinders tissue healing after injury tissues in prolotherapy treatments for ligamentous laxity (15). Our clinical experience suggests that diabetic patients (23). Testosterone’s beneficial androgenic effects on wound tend not to respond as well to regenerative injection therahealing, immune status, and inflammatory responses durpies as do non-diabetic patients (7,16). As the incidence ing acute wound healing have all been well documented. of obesity and diabetes continues to explode worldwide, dietary intervention is a critical component of naturopathic Testosterone production decreases with age in men and • Identify and treat the causes (tolle causam): The naturopathic physician seeks to identify and remove the underlying causes of illness rather than to merely eliminate or suppress symptoms.

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women and supplementation to physiologic levels appears to be safe (24).

Thyroid hormone stimulates metabolic rate. A hypothyroid state can lead to decreased wound healing and slowed stem cell proliferation (25). Thyroid production decreases with age and supplementation to physiologic levels appears to be safe (26).

Nutritional/Botanical Supplements Vitamins, Minerals, and Amino Acids

The roles that essential vitamins and minerals play in stem cell metabolism and function are well described in the basic science literature. The concept that a well-balanced micronutrient milieu is required for proper stem cell function is reasonable and based in the available data. The fat-soluble nutrients, vitamins A, D, E, and K, the water-soluble ascorbate, as well as every B-vitamin and associated nutrient (such as biotin and PABA) are critical for proper stem cell function.

The minerals copper, magnesium, iron, selenium, and zinc have been shown to be vital to stem cell function. Many amino acid structures, specifically acetyl-lcarnitine (ALCAR), tyrosine, tryptophan, lysine, glycine, glutamate, cysteine, and the tripeptide glutathione have been well studied in relation to stem cell metabolism and function.

An oral supplement regimen for patients undergoing stem cell therapy includes essential vitamins and minerals, essential fatty acid, dietary algae, and ALA.

Other Supplements

Fatty acids, such as fish oils and the omega 3 fatty acids are necessary for stem cell propagation. Basic antioxidants, in addition to those mentioned above, including anthocyanidins (blueberry and beet root), spirulina, green tea polyphenols, and fucoxanthin play a role in stem cell metabolism and function. Other cofactors such as alpha-lipoic acid (ALA) and ubiquinone (coenzyme Q10; CoQ10), as well as the trophic nutrients glycerophosphocholine (GPC) and phosphatidylserine (PS), appear to be required for proper stem cell function. Blueberry and fucoidan (a polysaccharide derived from brown seaweed) have been shown to promote stem cell release and function.

Based on these data, a reasonable oral supplement regimen for patients undergoing stem cell therapy would include essential vitamins and minerals, ideally in a multi50

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product formula, an essential fatty acid product, some form of dietary algae, and alpha-lipoic acid.

Intravenous Micronutrient Therapy

The administration of relatively large doses of micronutrients via the intravenous route (IVMT) is a novel method to replete a person before and during stem cell therapy. The premise of IVMT is that the serum concentrations of micronutrients taken orally are limited by GI absorption, whereas administering micronutrients intravenously achieves serum concentrations far beyond what GI absorption will allow, thereby better replenishing depleted cells (27). The basic nutrients such as the water-soluble vitamins and minerals can all be safely administered as IVMT. Likewise amino acids (as mixtures or separate additions), glutathione, and other support nutrients are also used in the IV form. A few specific nutrients for IV use are listed here: Alpha Lipoic Acid (ALA)

ALA is a thiol and as such is known in basic science to support levels of glutathione in the liver and other tissues. In experimental models, ALA has been shown to be helpful in pushing the redox balance in a positive direction via modulation of inflammatory cytokines such as tumor necrosis factor and NF-kappa-b.

Lipoic Acid Mineral Complex (LAMC)

Known as the proprietary formula Poly MVA® in North America, LAMC has shown to be helpful in cellular repair, mitochondrial repair, and radioprotection. We have found that low IV doses (5-15 mL) combined with low oral doses (5-10 mL BID) improve energy via mitochondrial support (28).

Taurine and Carnitine

Carnitine (either in the “l” form or the more bioavailable “acetyl-l” form) is useful in varied targets including decreasing neurotoxicity (29), decreasing lactic acid build up (30) as well as its more commonly known biochemical function of transporting fatty acids into the mitochondria for beta oxidation based energy production. We administer the l-carnitine form most frequently in IV doses of 500-4000 mg and the acetyl-l-carnitine form in doses of 100-1000 mg.

Taurine is the master osmolyte in the human body and as such regulates distribution of the excitable ions (Na, K, Ca, Mg, and Cl) to their appropriate sides of the cell membrane (31). In this role, we have observed adding 200-1000 mg taurine to IV formulas containing magnesium and other excitable tissue-acting minerals results in a greater benefit as reported by patients. Taurine is used constantly at the cell membrane and thus depleted both in low dietary intake as well as by oxidative stressors.

FROM THE CLINIC

Glutathione

Commonly used by doctors performing IVMT, glutathione appears to have positive effects in the treatment of a wide range of illnesses (32). General doses are between one and three grams but far greater doses have been documented.

As some patients will have sulfation SNP defects and other reasons not to tolerate glutathione, we typically use a lower test dose on the first IV infusion of glutathione, ranging from 100-500 mg.

Conclusion

Part I of this series has been intended to be an overview of the most basic and fundamental methods employed by the naturopathic physician for laying a foundation of optimal cellular metabolism, connective tissue health, and overall function of the human organism in order to optimize stem cell therapy. Part II of this series will detail the methods for harvest and concentration/isolation of bone marrow aspirate concentrate (BMAC) and adipose-derived stromal vascular fraction (SVF) and present original research comparing three methods for treating low back pain and osteoarthritis of the knee: 1) the use of bone marrow aspirate concentrate (BMAC); 2) the use of adipose-derived stromal vascular fraction suspended in platelet rich plasma (SVF/PRP); and 3) the use of SVF suspended in BMAC (SVF/BMAC).

References 1. Murphy MB, Moncivais K, Caplan A. Mesenchymal stem cells: environmentally responsive therapeutics for regenerative medicine. Exp Mol Med. 2013; 45:e54. doi:10.1038/emm.2013.94.

2. Hendrich C, Engelmaier F, Waertel G, Krebs R, Jager M.. Safety of autologous bone marrow aspiration concentrate transplantation: initial experiences in 101 patients.

Orthop Rev (Pavia). 2009 Oct 10; 1(2):e32.

3. Michalek J, Moster R, Lukac L, et al. Autologous adipose tissue-derived stromal vascular fraction cells application in patients with osteoarthritis. Cell Transplant. 2015 Jan 20.

4. Goldberg, Victor M. Stem cells in osteoarthritis. HSS J. 2012 Feb;8(1):59-61.

5. Quintero AJ, Wright VJ, Fu FH, Huard J. Stem cells for the treatment of skeletal muscle injury. Clin Sports Med. 2009;28(1):1-11.

6. Orozco L, Soler R, Morera C, et al. Intervertebral disc repair by autologous mesenchymal bone marrow cells: a pilot study. Transplantation. 2011 Oct 15;92(7):822-8.

7. Adelson H. Bone marrow and adipose derived autologous stem cells for the treatment of chronic musculoskeletal pain. Paper presented at Annual Meeting of the American Academy of Pain Management; September 2014; Phoenix, Arizona.

8. Pak J. Regeneration of human bones in hip osteonecrosis and human cartilage in knee osteoarthritis with autologous adipose-tissue-derived stem cells: a case series.

J Med Case Rep. 2011 Jul 7;5:296.

9. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015 Jun 16;350:h2747.

10. Radcliff K, Kepler C, Hilibrand A, et al. Epidural steroid injections are associated with less improvement in the treatment of lumbar spinal stenosis: a subgroup analysis of the Spine Patients Outcomes Research Trial. Spine (Phila Pa 1976). 2013 Feb 15;38(4):279-91.

11. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012 Dec 18;157(12):865-77.

12. American Association of Naturopathic Physicians. House of Delegates Position Paper.

Definition of Naturopathic Medicine. http://www.naturopathic.org/files/Committees/ HOD/Position%20Paper%20Docs/Definition%20Naturopathic%20Medicine.pdf.

Accessed August 3, 2015.

13. Hankenson KD, Watkins BA, Schoenlein IA, Allen KG, Turek JJ. Omega-3 fatty

acids enhance ligament fibroblast collagen formation in association with changes in interleukin-6 production. Proc Soc Exp Biol Med. 2000 Jan;223(1):88-95.

14. Mihaylova MM, Sabatini DM, Yilmaz Ă–H. Dietary and metabolic control of stem cell function in physiology and cancer. Cell Stem Cell. 2014 Mar 6;14(3):292-305.

15. Fadini GP, Pucci L, Vanacore R, et al. Glucose tolerance is negatively associated with circulating progenitor cell levels. Diabetologia. 2007 Oct;50(10):2156-2163.

16. Gallagher M, Moore T. Masqueraders of orthopedic pain: the gut-brain connection to chronic pain and the protocols to fix it. Presented at: 32nd Annual Conference and Seminar of the American Association of Orthopedic Medicine; April 2015; New Orleans, Louisiana.

17. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.

Lancet. 2012 Jul 21;380(9838):219-229.

18. Pizzorno JE, Murray MT. 4th Ed. Textbook of Natural Medicine. St. Louis, Missouri: Elsevier Health Sciences; 2012.

19. Petersen AM Pedersen BK. The anti-inflammatory effect of exercise. J Applied Physiol.

2005;98(4):1154-1162.

20. Hawke TJ. Muscle stem cells and exercise training. Exerc Sport Sci Rev. 2005;33 (2):63-68.

21. Crews FT, Nixon K, Wilkie ME. Exercise reverses ethanol inhibition of neural stem cell proliferation. Alcohol. 2004;33(1):63-71.

22. Kjaer M, Magnusson P, Krogsgaard M, et al. Extracellular matrix adaptation of tendon and skeletal muscle to exercise. J Anat. 2006 Apr;208(4): 445-450.

23. Ravin T. The use of testosterone and growth hormone for prolotherapy. J Prolotherapy.

2010; 2(4):495-503.

24. Gruenewald DA, Matsumoto AM. Testosterone supplementation therapy for older men: potential benefits and risks. J Am Geriatr Soc. 2003;51:101-115.

25. Lemkine GF, Raj A, Alfama G, et al. Adult neural stem cell cycling in vivo requires thyroid hormone and its alpha receptor. FASEB J. 2005;19(7):863-865.

26. Fatourechi V. Subclinical hypothyroidism: an update for primary care physicians. Mayo Clin Proc. 2009;84(1):65-71.

27. Ali A, Njike VY, Northrup V, et al. Intravenous micronutrient therapy (Myers’ Cocktail) for fibromyalgia: a placebo-controlled pilot study. J Altern Complement Med. 2009;15(3): 247-257.

28. Anderson P. IV nutrient therapy. Presented at: The Orthobiologic Institute 5th Annual PRP and Regenerative Medicine Symposium; June 2014; Las Vegas, Nevada.

29. Virmani A, Gaetani F, Binienda Z. Effects of metabolic modifiers such as carnitines, coenzyme Q10, and PUFAs against different forms of neurotoxic insults: metabolic inhibitors, MPTP, and methamphetamine. Ann N Y Acad Sci. 2005 Aug;1053:183-91.

30. Claessens YE, Cariou A, Chiche JD, Dauriat G, Dhainaut JF. L-Carnitine as a treatment of life-threatening lactic acidosis induced by nucleoside analogues. AIDS. 2000 Mar 10;14(4):472-3.

31. Lambert IH. Regulation of the cellular content of the organic osmolyte taurine in mammalian cells. Neurochem Res. 2004 Jan;29(1):27-63.

32. Ashtiani HR, Bakhshandi AK, Rahbar M, et al. Glutathione, cell proliferation and differentiation. Afr J Biotechnol. 2011;10(34):6348-6363.

Harry Adelson, ND, is the Medical Director, Docere Clinics in Park

City, Utah. Dr. Adelson practices exclusively autologous stem cell medicine for musculoskeletal pain conditions. He is a diplomate of the American Academy of Pain Management.

Tyna Moore, ND, DC, is the Medical Director of Core Wellness Clinic in Portland, Oregon. Dr. Moore practices exclusively Regenerative Injection Therapies, Naturopathic, Chiropractic and non-surgical pain management for orthopedic and musculoskeletal conditions.

Paul Anderson, NMD, is the Medical Director of Anderson Medical Specialty Associates, a clinic focusing on the care of patients with cancer and chronic diseases. He is a founding board member of the Academy of Parenteral Therapies specialty group.

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Location, Location, Location...

How Emotion Can Relate to Location of Pain

By Jennifer Johns ton, PhD, DNM, NMD

Research is well established on the influence of emotions on perception of pain, pain treatment, catastrophizing, and speed of healing. The Institute of Medicine reports, “people’s experience of pain can be influenced by genes, cultural attitudes toward hardships, stress, depression, ability to understand health information, and

other behavioral, cultural, and emotional factors. Successful treatment, management, and prevention of pain require an integrated approach that responds to all the factors that influence pain” (1).

Emotions of stress, joy, sadness, or even anxiety are all a natural part of life and are often felt physically. When

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Studies have established that emotions have distinct biological expressions that influence overall health.

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preparing to step on the stage to give an important speech we may feel our anxiety as a physical sensation of knocking knees or even butterflies in the stomach. When meeting to go on a first date we may experience anxious feelings as a flutter in the chest, swirling feeling in the head, or nervous smile. Each of us may describe how we experience a situation differently, but most agree on how basic feelings are experienced in the body.

When emotions become excessive, suppressed, or turned inward they may begin to influence our overall physical function and how and where we perceive pain. Studies have established that emotions have distinct biological expressions that influence overall health. Additionally, emotions are responsible for prompting the body to prepare us to react to environmental challenges by communicating with the cardiovascular, skeletomuscular, neuroendocrine, and autonomic nervous system. For example, stress can both be the cause and influencing factor for a variety of physi-

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ological responses that can enhance health or promote disease (2). When we sense fear our flight or fight responses are activated and we feel that fear in the body. By taking a deeper look at how emotions correlate with the location of pain we may find a deeper understanding on why and how patients experience pain.

Body Mapping

In 2014 researchers were able to identify locations of body sensations related to emotions using a topographical body mapping method. Results reveal consistent and distinct maps associated with basic emotions. Physical sensory information is known to trigger conscious emotional experiences. This study showed that different emotional states are associated with distinct and culturally universal body regions. These regions could aid in our understanding of how emotions correspond with pain locations in the body (See Figure 1) (3).

Figure 1.

Anger

Fear

Disgust

Anxiety

Love

Depression

Happiness

Contempt

Sadness

Surprise

Neutral

Pride

Shame

Envy

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Figure 2.

Spleen & Stomach Kidney & Bladder Liver & Gallbladder Lung & Large Intestine Heart & Small Intestine Pericardium & Triple Warmer

Researchers ran five studies with a total of 701 participants and identified that different emotions were reliably associated with statistically identifiable bodily sensation.

These maps were equal among both West European and East Asian samples. They propose that emotions are represented in the somatosensory system as culturally universal categorical somatotopic maps (3).

TCM: Emotions and Meridians

Traditional Chinese Medicine (TCM) views the body as a whole, with mind, body, and emotions as correlated factors influencing overall health and happiness. A TCM fundamental principle states that everything experienced on the outside of the body reflects the quality of health on the inside (4). Certain areas of the body are more vulnerable to injury due to potential underlying emotion, energy, or organ imbalance. Many individuals experience a physical event, such as a slip or fall, so why do some experience injury and others do not? Why do some individuals experience injuries to their knee, ankle, hip, low back, or wrist?

Why is there so much variation in the potential for injury and the location of the injury?

Sports Medicine Journal reported that 1.5 million young men participate in football and an estimated 1.2 million football-related injuries are reported annually. Overall,

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50% of all injuries were lower extremity injuries (with knee injuries accounting for up to 36%). Thirty percent of injuries occurred in the upper extremities. Overall, sprains and strains accounted for 40% of injuries, contusions 25%, fractures 10%, concussions 5%, and dislocations 15% (5).

Pain can result from an external source, such as an auto or sports injury that damages the meridians and physical structure, as well as from an internal condition, such as an organ or energy imbalance. It is often easier for the practitioner to identify and treat the cause when it is related to external visible factors. Pain related to internal or emotional conditions has a tendency to be more complex, and effective treatment requires a closer look to determine the root cause.

All emotions can influence the body’s response to external factors such as injuries and accidents. It is when emotions become out-of-balance, excessive, or repressed that overall health and pain responses are influenced. Excessive or repressed emotions are understood to contribute to organ imbalance thereby leaving the body more susceptible to physical damage, pain, and injury.

The reverse is also true. Individual organ health can similarly influence the experience of emotions and pain.

The theory is that balancing the organ that is associated with the emotion results in a balancing of the associated emotion. Sometimes the organ is out of balance and produces the emotional imbalance or potential physical vulnerability for injury. The difference is important to the practitioner in identifying and reducing future recurrence of the symptom.

Meridians are a three-dimensional energy network in the body that make pathways that connect to each other and to every bone, tendon, tissue, organ, and skin cell.

These intercommunication networks function within the entire physical and emotional framework. There are 12 major meridians that run through the body (4). The left and right sides of the body mirror each other, while the back and front are different. Each meridian corresponds to an internal organ along with the associated emotions and other similar energy frequencies. (See Figure 2).

Liver and Gallbladder.

An individual experiencing feelings of anger, frustration, irritability, and stress may be suffering from a liver imbalance. Liver and gallbladder meridians are correlated with migraine headache, tendon and ligament problems, ankle and hip pain, menstrual cramps, and arthritis. When the liver becomes healthier, the associated physical pain and

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emotion will reduce or disappear. However, a persistent lifestyle situation that increases or continues feelings of stress and anger will cause the liver imbalance to continue, along with the associated pain (4).

Spleen and Stomach.

The spleen and stomach are associated with feelings of worry and over-thinking. Imbalances in these meridians can result in excessive or easy bruising, muscle injuries, or pain conditions related to the torso, front of the legs, and feet. Pain felt in the big toe can be linked to digestive imbalances involving the liver and spleen, as both meridians end in the big toe (4).

Kidney and Bladder.

The kidney and bladder are associated with the emotions of fear and anxiety and their meridians are further related to pain associated with the knee, heel, neck, low back, feet, and bones. In a case study involving kidney function and meridian location, a female reported sore knees after skiing season and a subsequent right knee injury resulting from skiing (6). In this case, the sore and injured knees are related to the activity of skiing but, why the knees and not the hips or ankles? TCM theory links the state of the individual’s kidney energy and function to the health and resilience of the knee area (4).

Lung and Large Intestine.

The lung and large intestine are associated with the emotions of sadness, depression, and grief. Pain conditions correlated with these organs and their meridian locations include painful skin conditions and shoulder, elbow, and hand injuries (4).

Heart and Small Intestine.

The heart and the small intestine are related to the emotions of joy and happiness and are further associated with pain experienced in the upper body, chest, shoulders, and hands.

For instance, a broken heart from a problematic relationship will eventually cause an organ function disorder if the emotion is not addressed and resolved. Joy is the heart’s corresponding emotion. When an individual loses the capacity to experience joy, the heart’s health can be negatively affected resulting in both physical and emotional pain (4).

Due to the complexity of pain and emotions, the diagnostic process should include many questions related to lifestyle, emotional wellbeing, and physical health to aid in

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EMOTION AND LOCATION OF PAIN

identifying the root cause of the pain. Our job as practitioners is to help patients evaluate all contributing factors related to their pain condition, not just the physical. Once the key underlying cause is identified, then the imbalance can be addressed and the environment that created that imbalance can be changed.

Additionally, when considering emotional correlates to pain it is important to remember that cause and effect are not linear but circular. For example, after an auto accident we can say that the accident caused a neck injury, but why the neck location for that individual? The sore neck is the symptom of the effect of the auto accident which is the cause. But what set the stage for the injury in the first place?

Pain can be a complex symptom and the cause may not be so straightforward, which is especially true when dealing with emotional factors. Which preexisting emotional patterns or organ imbalances have contributed to the individual’s specific pain symptoms and locations? We have the opportunity as practitioners to identify underlying factors that contribute to pain in order to help patients relieve and/or reduce the manifestation of pain.

Finding the time to help our patients identify emotional and lifestyle factors related to pain symptoms can be challenging. It is also important to take the time to examine and identify how our own personal choices influence our physical and emotional experiences. Finding time to relax, take a nap, or have some much needed fun is always a good first step toward improved health and happiness.

References 1. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011.

2. Institute of Medicine (US) Committee on Health and Behavior: Research, Practice, and Policy. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: National Academies Press (US); 2001.

3. Nummenmaa L, Glerean E, Hari R, Hietanen JK. Proc Natl Acad Sci USA. 2014; 111(2):646–651.

4. Nan L, Schaplowsky E. Traditional Chinese Medicine: A Natural Guide to Weight Loss That Lasts. New York, NY; TCM World Foundation; 2000: 139-142, 159-161, 180, 200203, 218-223.

5. Saal JA. Common American football injuries. Sports Med. 1991;12(2):132-147.

6. Nan L. Ask Dr. Lu: Volume One. New York, NY: TCM World Foundation; 2011: 97-99 & 121-122.

Jennifer Johnston, PhD, NMD, MS, is a board-certified practitioner

at Holistic Health Solutions, Inc. with more than 13 years’ experience in naturopathic and Traditional Chinese medicines. She has a master’s of science with studies in psychoneuroendocrinology and a doctorate in clinical nutrition. Dr. Johnston is part of TCM World Foundation’s advanced studies program and is certified to practice LifeForce: Tao of Medical Qigong, Dragon’s Way®, Menopause and Breast Health programs.

THE PA IN PRACTITIONE R

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DEPARTMENT

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