Kenneth Craig, Bradley Takai, Daniel Poratt

Presenter: Kenneth CraigMedical Director Kompass Health Associates

Kompass OrthoShock Centre of Extracorporeal Shockwave Therapy & Research

Auckland, New Zealand

Medical shockwaves a treatment option for complex / neuropathic pain

syndromes?

A compilation of case reports 2012 – 2014

Conflict of Interest Declaration

Royalties & stock options – NONE

Consulting Income – NONE

Research & Education Support – NONE

Other support - NONE

AIM

To discuss and invite more research in this area

Complex / Neuropathic Pain

-

(Dorkin et.al., 2003 & 2007; Ducreux et.al., 2006; Costigan et al., 2009; Nielson et.. al, 2008; Staud et.al., 2008; Tracey & Mantyh, 2007; Treede et. al., 2008).

Introduction

Poorly understood

Maladaptive

Abnormal sensory perception

Multifactorial propagation

Indocile to most interventions

(Mainly symptomatic control)

Severe impactPeripheral hyperalgesia,

allondynia

2ndary

hyperalgesia &

allondynia

Peripheral /

Central

Ectopic

activity

To find an effective homeostatic disease modifying treatment modality that is:

Non-invasive

Systemically neutral

Economically viable

The Need

ESWT?

The Answer

Our Case Series

Brief Case Description

Gender Male (n=5); Female (n=7)

Age (Mean) 44 yrs; Y(14yrs) / E (70yrs)

Inciting Event Trauma (n=10) – CRPS1; Infection (n=2) - Neuropathic

Region of Interest Foot & Ankle (n=10); Knee (n=2)

Mean Disease Duration 16 months

P & S Hyperalgesia n=12

P & S Allondynia n=12

Emotional Distress n=12

Management

Primary analgesia & NSAID’s

Secondary analgesics (TCA’s / Anticonvulsants)

Opioid analgesia (Tramadol / oxycodone)

Physical therapy

Counselling + alternative therapies (ie hypnotherapy)

Baseline Investigations

General history taking

Psychometric

POP 3 (20 pt questionnaire)

Subjective Pain (0 – 10)

Physical Index (% of Mobility; ADL; Vitality)

Affective Index (% of Emotional status & Fear)

Neuropathic

questionnaireDN4

Clinical tests DermaTemp; NeuroTip; Monofilament; Cotton-brush

Physical assessment Passive / Active ranges & movement observation

EducationPain education

Technology education

Material s & Methods

Phamacogenic

s

All discontinued prior to Tx and remained throughout

Device Electrohydraulic (MediSpec)

Treatment # 4 at 1 week intervals

Impulse # 1500 / Tx (500 impulses over each region)

EFDL 0.08mj/mm² (initial 2); 0.10 – 0.14mj/mm² (3rd- 4th)

Tx regions Primary & secondary regions, and along neural course

0

1

2

3

4

5

6

7

8

9

10

Baseline Week 6 Week 12 Week 24

Pain (VAS)

DN4

Results

Positive response: n=10 (trauma induced)

VAS Pain score: (8.87) to 2 at w24

DN4 Score: (6.7) to 0 at w24

Results

0

10

20

30

40

50

60

70

80

90

Pre Tx Week 6 Week 12 Week 24

Physical Index

Affective Index

Physical Index: (53.47) to 2.77 at w24

Affective Index: (85.49) to10.22 at w24

Discussion

n=2 non-respondents – infection incited (unchanged from onset)

n=10 CRPS - Abnormal pain symptoms & sensitivity settled

No adverse complaint to-date (n=12)

Discussion: Rational for Application

(Bee & Dickenson, 2008; Costigan et al., 2009; Keller et.al., 2007; Koban et. al., 2003; Kohno et.al., 2005; Matsuzawa-Yanagida et.al., 2008; Miraucourt et.al., 2007; Pearl, 2007; Schattschneider

et.al., 2006; Schloz et.al., 2007; Vera-Portocarrerro et.al, 2006; ).

Peripheral abnormaly (Increased

nociceptive barrage, aberrant

inflammatory, immunological interactions

etc.)

Central abnormaly (sensitisation &

aberrant inflammatory, immunological

interactions etc.)

Reduced descending inhibition

Reduced inhibitory polarisation modulators

Neuro-transcription (pain memory)

Nutritive vessel hypoxia =

small fiber damage

ESWT proposed mechanics of action:

Modulates inflammatory substances

Modulates immune response

Improves perfusion – hypoxic correction

Regenerative and restorative capacity

Unique stimulus – cognitive capturing / arousing

Certainly more research is warranted

Future Direction & Conclusion

Continue to monitor these cases

Research collaboration with pain

centres (ie TREND / TARPS)

More measurable Tx. outcomes

(dorsaVi) to help expand recognition

and use of ESWT

Certainly worthwhile investigating

THANK YOU

1. Angehrn, F., Kuhn, C., Sonnabend, O. & Voss, A. (2008). Impact of extracorporeal shock waves on the human skin with cellulite: A case study of an unique instance.

Clinical Interventions in Ageing, 3(1) 175 – 182

2. Bee LA, Dickenson AH. 2008. Descending facilitation from the brainstem determines behavioural and neuronal hypersensitivity following nerve injury and efficacy of

pregabalin. Pain 140(1):209–23

3. Costigan, M., Scholz, J. & Woolf, C. J. (2009). Neuropathic Pain: A Maladaptive Response of the Nervous System to Damage. Annual Review of Neuroscience, 32, 1

– 32.

4. Ducreux, D., Attal, N., Parker, F. & Bouhassira, D. (2006). Mechanisms of central neuropathic pain: a combined psychophysical and fMRI study in syringomyelia.

Brain 129(part4), 963 – 976.

5. Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, et al. 2003. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations.

Arch. Neurol. 60:1524–34

6. Dworkin, R. H., O‘Connor, A. B., Backonja, M., Farrar, J. T., Finnerup, N. B., Jensen, T. S., Wallece, M. S. (2007). Pharmacologic management of neuropathic pain:

evidence-based recommendations. Pain, 132(3), 237 – 251.

7. Finnerup, N. B., Sindrup, S. H. & Jensen, T. S. (2010). The evidence of pharmacological treatment of neuropathic pain. Pain, 150(3), 573 – 581.

8. Kembler M. A., De Vet H. C.W., Barendse G.A., Van Den Wildenberg F. A. J . M, Van Kleef M. (2008). Effect of Spinal Cord Stimulation for Complex Regional Pain

Syndrome Type -1: a five year final follow-up of patients in a randomised controlled trial. Journal of Neurosurgery, 108(2), 292 – 298.

9. Koban M, Leis S, Schultze-Mosgau S, Birklein F. Tissue hypoxia in complex regional pain syndrome. Pain 2003;104:149–57.

10. Kohno T, Ji RR, Ito N, Allchorne AJ, Befort K, et al. 2005. Peripheral axonal injury results in reduced mu opioid receptor pre- and post-synaptic action in the spinal

cord. Pain 117:77–87

11. Kroenke, K., Krebs, E. E. & Blair, M. J. (2009). Pharmacotherapy of chronic pain: a synthesis of recommendatins from systemic reviews. General Hospital Psychiatry,

31(3), 206 – 219.

12. Kumar K., Rizvi S. & Bnurs S. B. (2011). Spinal Cord Stimulation Is Effective in Management of Complex Regional Pain Syndrome 1: Fact or Fiction. Neurosurgery,

69(3), 566 – 580.

Reference

14 Matsuzawa-Yanagida K, Narita M, Nakajima M, Kuzumaki N, Niikura K, et al. 2008. Usefulness of antidepressants for improving the neuropathic pain-like state and

pain-induced anxiety through actions at different brain sites. Neuropsychopharmacology 33:1952–65

15 McGeeney, B. E. (2009). Pharmacological Management of Neuropathic Pain in Older Adults: An Update on Peripherally and Centrally Acting Agents. Journal of Pain

and Symptom Management. 38(2S), S15 – S27.

16 Miraucourt LS, Dallel R, Voisin DL. 2007. Glycine inhibitory dysfunction turns touch into pain through PKCgamma interneurons. PLoS ONE 2:e1116

17 Nielsen CS, Stubhaug A, Price DD, Vassend O, Czajkowski N, Harris JR. 2008. Individual differences in pain sensitivity: genetic and environmental contributions.

Pain 136:21–29

18 Notarnicola, A., Moretti, L., Tafuri, S., Panella, A., Filipponi, M., Casalino, A., Panella, M. & Moretti, B. (2010). Shockwave therapy in the management of complex

regional

19 Perl ER. 2007. Ideas about pain, a historical view. Nat. Rev. Neurosci. 8:71–80

20 Saginni, R., Figus, A., Troccola, A., Cocco, V., Saggini, A. & Scuderi, N. (2008). EXTRACORPOREAL SHOCK WAVE THERAPY FOR MANAGEMENT OF CHRONIC

ULCERS IN THE LOWER EXTREMITIES. Ultrasound in Medicine & Biology, 34(8),1261–1271.

21 Sandkuhler J. Models and Mechanisms of Hyperalgesia and Allondynia. Physiological Reviews. 2009; 89(2):707–758.

22 Sansone, R. A. & Sansone, L. A. (2008). Pain, Pain, Go Away: Antidepressants and Pain Management. Psychiatry, 5(12), 16 – 19.

23 Staud R, Craggs JG, Perlstein WM, Robinson ME, Price DD. 2008. Brain activity associated with slow temporal summation of C-fiber evoked pain in fibromyalgia

patients and healthy controls. Eur. J. Pain 12(8):1078–89

24 Schaden, W., Thiele, R., Kölpl, C., Pusch, M., Nissan, A., Attinger, C. E., Maniscalo-The berge, M. E., Peoples, G. E., Elster, E. A. & Stojadinovic , A. (2007). Shock

Wave Therapy for Acute and Chronic Soft Tissue Wounds: A Feasibility Study, 143 (1) 1 – 12.

25 Tracey, I & Mantyh, P. W. (2007). The Cerebral Signature for Pain Perception and Its Modulation. Neuron, 55(2), 377 – 391.

26 Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, et al. 2008. Neuropathic pain: redefinition and a grading system for clinical and research purposes.

Neurology 70:1630–35

27 Vera-Portocarrero LP, Zhang ET, Ossipov MH, Xie JY, King T, et al. 2006. Descending facilitation from the rostral ventromedial medulla maintains nerve injury-induced

central sensitization. Neuroscience 140:1311– 20

28 Woolfe, C. J. & Ma, Q. (2007). Nociceptors – Noxious Stimulus Detectors. Neuron, 55(2), 353 – 364.

Reference