Today I am going to complete this discourse.  Enjoy.  Remember, typically in chronic pain syndromes–15 – 20% of the hurting arises from the actual healed injury, the remainder is secondary to a “learned pain state” which is correctable.

BEYOND WESTERN MEDICINE: PAIN MODELS AND TREATMENT EFFICACY

Michael Jon Kell, MD PhD

Subjects: The subject population consisted of 60 patients referred to our pain center for evaluation and treatment of neuropathic pain syndromes, both with and without ongoing evidence of an existing peripheral pain generator. Upon admission, all patients were thoroughly evaluated as to the source and etiology of their admitting problem. All referring diagnoses were verified. A complete history of prior treatment was obtained. Patients were also interviewed (and tested) as to psychiatric comorbidity, psychosocial environment, daily functioning and so on. All patients were admitted to the study if they displayed at least one physical sign associated with a current or prior nerve injury: hair changes, nail changes, edema, vasoconstriction, hyperalgia, hyperpathia, allodynia and so on.
Methods: Following evaluation patients were prescribed individualized treatment, including, physical and massage therapy, medication management, coping skills, electromedicine, family and individual therapy. Interventions were adjusted based upon the response of the patient. Following initial stabilization in pain scores and daily activities levels, each patient was introduced to the new pain model via individual instruction by the author.

The information utilized to modify each patient’s concept of causality was presented so to be congruent with the patient’s religious upbringing, educational level, social status, prior belief systems and past traumatic experiences.5 Often times reframing was done by discussing how the old concept of linear causality had failed the patient in effectively dealing with the many factors associated with past, especially emotionally charged event. Buddhist psychological concepts (though not always labeled as such) were gradually presented each patient. Generally, it took several weeks of intensive reframing (one or two sessions per week) to begin to see noticeable improvements.
Results: In over 90% of these patients, we reversed the previous treatment failures, obtaining good to excellent results in decreasing pain and improving function, by simply reframing a patient’s understanding of his or her pain syndrome. Decreases in perceived pain intensity (pre: 4.6{SD 0.55}, post: 1.2{SD 0.35}), increase in hours actively involved in daily activities (pre: 5.2{SD 3.1}, post: 14.3{SD 2.8}) and improvement in psychological status as shown by the general severity scale of the SCL-90-R (pre: 72{.6}, post 20{8.9}).
Included is a case summary of a typical patient presenting to this study for whom spiritual matters were non-linearly involved in his pain syndrome.
Case Study: The first case discussed is typical of the patient who presents to a pain clinic having been provided as a child with a solid, though partially negative, religiospiritual upbringing. Interventions will require modification of a current belief system.
WG, a 40 year old married male, presented to our clinic with a 2 year old history of neuropathic pain in the upper left extremity initiated by an industrial laceration to his index finger due to carelessness (later worsened by a misplaced axillary block). Visual examination revealed massive swelling in the extremity accompanied with hair, skin and nail changes consistent with RSD late stage II or early stage III disease. The patient complained of constant and excruciating burning pain and episodes of massive edema with skin breakdown. He was extremely protective of the extremity, not wanting anyone to come near or touch it. Sensory loss was consistent with an injury to the distal portions of the brachial plexus. He was unable to work.
Bilateral current perception testing demonstrated severe anesthesia to 2000, 250 and 5 Hz signals in the distribution of the left median and ulnar nerve below the axilla (suggestive of an iatrogenic neuropathic nerves block injury). Based upon our evaluation, he was diagnosed with major causalgia.
The initial psychological evaluation demonstrated the presence of a mild, reactive depression and a dependent personality disorder.
Over the year previous to admission to our office, medical treatment included active physical therapy, TENS, multiple stellate ganglion and axial nerve blocks and the prescription of large doses of meperidine. He was iatrogenically addicted to opioids upon admission.
Upon admission to our office he was withdrawn from short-acting opioids and placed upon maintenance methadone. Methadone dose was adjusted upwards (daily methadone of 100 mg) until a generally, therapeutic blood level had been obtained.15 WG, contrary to our expectations based upon
experience with similar patients, responded only partially to methadone and was subsequently placed upon multiple other medications thought helpful for causalgia (including IV lidocaine and phentolamine
challenges). As the result of his generally poor response, it was deemed important to search for atypical psychogenic maintenance factors. He was referred to an in-house minister.
After several interview sessions constructed around the religiospiritual questionnaire (Table 1), it became apparent there were underlying spiritual problems stemming from deep-seated feelings of emotional guilt, low self-esteem and repressed anger. The need to address these underlying spiritual problems and concerns were based upon the following discoveries.
WG was raised in a family where both parents were religious and active within the Protestant church. He and his wife are born-again Christians. At one point in his life, due to his religious fervor, he felt a desire to enter into the ministry. However, after attending seminary for a short while, he dropped out. Following this, while on his job he had an accident involving his left hand and wrist. He, as well as his wife, repeated on numerous occasions that they believed that with God’s will he would be healed.
Further, he exhibited deeply repressed feelings of not being able to forgive himself for having dropped out of seminary. These were mixed with feelings that God may be punishing him for his transgression of faith. A scriptural verse from the Bible that could be used to express the nature of his spiritual pain is found in Luke 9:62, where Jesus said, “… No man, having put his hand to the plow, and looking back, is fit for the kingdom of God.”
After several months of spiritual counseling this patient learned to accept that his illness and the resulting limitations caused by loss of the use of his left upper extremity was simply “an accident” and not “an act of retribution from God”. His pain quickly diminished and he was subsequently weaned from all medications and discharged with a recommendation to return to the seminary or attend vocational rehabilitation. At a twelve month follow-up visit, examination revealed trophic changes consistent with developed Stage III. Burning pain had remained minimal over the 12 month period and functional use of the arm had improved slightly. He had not as yet returned to seminary or vocational rehabilitation.
Religious and Spiritual Beliefs Questionnaire: Over the past several years, we have employed a structured set of interview questions for exploring the religious and spiritual beliefs of our patients (enclosed below). Both staff members and patients have found it beneficial for sanctioning the inclusion of spiritual issues into the therapeutic setting.
Table 1. Structured Religious and Spiritual Beliefs Questionnaire
(1) Do you believe in God?
(2) What is your concept of God?
(3) How important is God in your life?
(4) What are your current religious beliefs (Christian, Jewish, etc.)?
(5) Are you a member of a church? What church?
(6) Did you have a religious/spiritual upbringing?
(7) Are you living in accord with your childhood doctrines?
(8) Is there anything you feel guilty about?
(9) Do believe God forgives?
(10) Have you ever had a near death experience?
(11) Do you believe in life after death?
(12) Do you believe in prayer?
(13) Do you believe God answers prayers?
(14) Do you believe God rewards and punishes?
(15) Do you believe God is responsible for disease and suffering?
(16) Do you believe God heals?
References:
1. Pain centers: a revolution in health care, ed. Aronoff GA, New York: Raven Press, 1988.
2. Turner JA et. Al. The importance of placebo effects in pain treatment and research. JAMA 1994;271(20):1609-1614.
3. Substance abuse: a comprehensive textbook, 2nd edition, Lowenstein JH, Ruiz P, Millman RB, Baltimore:Williams & Wilkins, 1992.
4. Bhikkhu Nanamoli. The life of the Buddha. Kandy, Sri Lanka: Buddhist Publication Society, 1992.
5. Culver MD, Kell MJ. Working with chronic pain patients: spirituality as a part of the treatment protocol. AJPM 1995;5(2):55-61.