Pain articles inconsistent

[dejerine]

A recent article on Medscape on Neuropathic Pain left me puzzled. It was written by an anesthesiologist.

See
http://www.neurology.org/cgi/content/abstract/62/5_suppl_2/S30

It was authored by someone who has published elsewhere on central pain, but in this article, he displays graphs showing post stroke CP, but omits post SCI pain. This seems odd since the prior article in Neurology is very specific about Post SCI pain. That article was effusive in including the various "proven" treatments, and indicated that various remedies had been effective for the central pain syndromes including antiepileptics, opioids, etc. Other than the one article cited recently here by Dr. Young the only prospective double blind sutdy on any neuropathic pain cure I have seen has been on postherpectic neuralgia and elavil, not on central pain.

Yet, these are the very therapies that have been questioned repeatedly over the years. Authors who advocated for opioids have now changed their view and are saying opioids are not the answer. It would be very difficult to find articles which quantify ANYTHING when talking about pain benefit, often omitting any discussion or objective criteria of quantification of benefit which even remotely resembles a double blind or prospective data array, or anything resembling what is normally required in any other field of medicine.

Double blindedness and prospective study design don't seem to have arrived in central pain publications. Anyone who looks at the history of medicine knows how perilous and delusional studies can get if they lack proper design.

I welcome ANY publicity given to the pain states, but cannot understand the omission of CP. The article by Nicholson had many impressive graphs on benefits to life style from various approaches, but I become uneasy about such items as "benefit" or "improvement" since they are nowhere quantified.

Do we say if something shows 5% improvement in a relatively small cohort of patients, that we have shown the drug is actually effective. Even if there is one hundred percent "benefit", the same might be said for almost any sedative. This is the sort of "benefit" that fuels much of the herbal medicine, "natural" remedy industry--lacking specific quantification that allows the public to know if the benefit is significant.

If I have cancer, we can talk about survival in five years, but showing that someone was more active in life doesn't necessarily mean the pain was better. I admit we do a crummy job of verbalizing central pain to doctors, but sometimes I think they do an equally crummy job of evaluating therapies. "Ideas must be distinct before reason can act on them"--Thos. Jefferson.

Talk of pain benefit was behind the decades of mistaken belief that removal of the superioir cervical ganglion stopped sympathetically maintained pain. The same sort of language is in all the now disproven literature on the benefit of opioids for central pain. There are elaborate studies on the benefit of Neurontin but very little to show it stops severe burning in CP. Can we expect any difference in Pregabalin (Lyrica) when both drugs, Neurontin and Pregabalin are said to block the same chemical step. I wonder if the severity of pain allows a lot of adventuring without hard data, if severe pain makes people crazy and almost any change in that is considered a benefit worth being called a pain treatment. I hope I am wrong. None of it has done anything for me and so I have to ask these questions. Does the emperor have any clothes on???


Now the entire condition of post SCI pain is not displayed in a review article granting continuing medical education credit to doctors and nurses on a national site. John Bonica estimated there were at least one hundred thousand with post SCI pain and related conditions. The omission might make doctors LESS aware of SCI central pain than more aware of how to receive pain complaints. It always helps if people have at least HEARD of something.

One has to wonder if the doctors are actually seeing and treeting much Post SCI pain if they forget to mention it; or should we pay attention only to the docs in rehab units, since they seem to be quite familiar with CP.
This whole business is unnerving. Pain experts who fail to include the most severe variety of neuropathic pain???

[This message was edited by dejerine on 04-14-05 at 02:46 PM.]

[Joe B]

Dejerine,

I really appreciate the sentiment you expressed in your article. There is no consistent understanding of what is CP and how can it be treated. At David Berg's site, he details how many neuropathic pains are related. Trauma to the brain, postherpetic pain, and even diabetic nerve pain exhibit similarities but each may have a distinctly separate cause. One to the brain, another to the spinal cord, and another to peripheral nerves.


Central pain has been described to me as a pain that is in the head probably in the brainstem area and a result of a lack of normal signals from the sensory nerves. On the other hand, I have heard it described as a result of sensory nerves firing and being misinterpreted as pain. I strongly believe that we have failed to differentiate between to effects that exhibit the same result.

My own CP exhibits response to the evironment. Cold, Air Conditioning, light pressure on surfaces below my injury all tend to increase the pain. Yet I know SCI and non-SCI who have said that their condition does not respond to the environment but causes the same burning, dipped in acid feeling. Somehow these are different actions with similar pain effects.

While it is probably helpful to lump the many people with this burning pain together because it increases the number of sufferers and raises the visibility and priority, it confuses researchers because the pain is the result of different causes and probably will respond to studies differently.

I also loved that you noted that sometimes when there is a "benefit" from a treatment it sometimes gets descibed as a an "effective treatment." Neurontin or Elavil take the edge off my pain enough for me to stop thinking about how soon can it possibly end (death has no terror for me, but appears as a promised land). The Drs and Nurses who appear here at CareCure, understand that while some drugs are beneficial, they are not effective treatments but only ablate some of the worst of the pain. But reseearchers who do not spend time around SCI with CP can be impressed by a research survey that shows "benefit" of 5%.

I took part in a pain study that taught me visualization and relaxation techniques to help deal with pain. These techniques did lessen my pain but were temporary and I found in my real/normal/everyday world were not able to be maintained effectively.

You hit many other good points and I will not reassert them here. But critical care must be taken when assessing similar pains for a basis for research.

The other thing that we unfortunately must bear with is that in our medical world, meaningless research is common and frequently nothing will be done with the results. We have to hope that good will come out of some of the research but for now central pain research is undirected and unfocused.

Joe B
C6-7
1988