Before discussing the role of Neuroplasticity in chronic pain management it is important to have a working definition of the term. Neuroplasticity (variously referred to as brain plasticity or cortical plasticity or cortical re-mapping) refers to the changes that occur in the organization of the brain as a result of learning and experience. A surprising consequence of neuroplasticity is that the brain activity associated with a given function can move to a different location within the brain as a consequence of normal experience or brain damage/recovery.

It is now indicated that this capacity for rewiring of the neuronal synapses to allow for re-development of entire regions of the brain is present in adults as well as children. Newly discovered principles of adult neuroplasticity are at the heart of some of the most revolutionary and groundbreaking brain research.

Pain research presented by the American Society of Anesthesiologists has emphasized the molecular transduction of painful stimuli, the sensitization processes that occur after injury and long-term phenomena such as pain memory. Neuroplasticity after surgery occurs at the transduction process, in the periphery at the sub-cellular level, or in the central nervous system, where central sensitization occurs.

According to Kenneth Sufka in his article published in Brain and Mind Journal in 2004:

Pain that persist long after damaged tissue has recovered remain a perplexing phenomenon. This so-called chronic pain serves no useful function for an organism and, given its disabling effects, might even be considered maladaptive. However, a remarkable similarity exists between the neural bases that underlie the hallmark symptoms of chronic pain and those that serve learning and memory. Both phenomena, wind-up in the pain literature and long-term potentiation (LTP) in the learning and memory literature, are forms of neuroplasticity in which increased neural activity leads to a long lasting increase in the excitability of neurons through structural modifications at pre- and post-synaptic sites.

Research published in Pain Physician Journal (2006) indicated that 90 percent of people in the US receiving treatment for pain management are prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. According to research published in Annals of the New York Academy of Sciences 933:175-184 (2001) titled “Spinal Cord Neuroplasticity following Repeated Opioid Exposure and Its Relation to Pathological Pain;” convincing evidence has accumulated that indicates there are neuroplastic changes within the spinal cord in response to repeated exposure to opioids. Such neuroplastic changes occur at both cellular and intracellular levels. Since so many people living with chronic pain are using opiates these neuroplastic changes need to be better understood.

Since chronic pain is a biopsychosocial condition it makes sense that the treatment plan would include the physical, psychological and social domains as well. One important part of the biological treatment plan for many people living with chronic pain should be physical therapy that can be either active or passive in nature. Active physical therapy for pain treatment involves numerous stretching techniques and specific exercises whereas passive pain therapy may include varying temperature packs are often used as a form of relief. The goal is to heal and prevent injury as well as improve a person’s range of motion.

I have quoted the information below from the International Association for the Study of Pain (IASP) on the role of the Physical Therapist as part of a multidisciplinary chronic pain management treatment team. I have been a member of the IASP since 1999 and have learned a great deal from their research and experience. To learn more about the IASP— and to explore the benefits of membership— please go to their website at www.iasp-pain.org.

Health care has changed in recent decades. Early activity for recovery of function is now encouraged, and the impairment model has broadened to include psychosocial components. A multidisciplinary team approach now includes the patient as an educated and active participant, and physical therapy treatments emphasize activity. The therapist's role has changed from healer to helper.

Therapists help patients address and overcome physical and psychological obstacles, return to activities, and achieve personal goals. Recognition of a broad biopsychosocial model of health (and illness) and the positive role of activity in health and healing, emphasis on function rather than impairment, and reliance upon clinical evidence have transformed physical therapists' practice.

For chronic pain sufferers the process of rehabilitation to a life less dominated by pain can be long and complex. Rehabilitation involves overcoming physical and psychological obstacles. Physical therapists are important to pain management. They help patients address obstacles to rehabilitation and to use information, and provide helpful feedback and reinforcement to guide efforts toward a return to activities and achievement of valued personal goals.

Physical therapists have incorporated cognitive and behavioral principles into rehabilitation and use a comprehensive biopsychosocial model of pain management that is patient-centered, time-limited, and goal-oriented. Their rehabilitative approach and fundamental concern with restoration of movement and function make physical therapists essential to the collaborative approach required for effective pain management. Their rehabilitative approach and focus upon restoration of movement and function make physical therapists essential to the collaborative approach required for effective [chronic] pain management.

The information below is posted with the generous permission of Dr. Eugene G. Lipov, the developer of a new cutting edge process that is helping many people living with severe chronic back pain as a result of failed back surgery. I am posting this information in its entirety in the hope that it may prove beneficial to my readers. I plan to follow Dr. Lipov’s progress and wish him the best in his ongoing development of this breakthrough process.

"Mix of 2 pain-relief procedures can end chronic back and leg pain without drugs"
By Eugene G. Lipov, MD and Jay R. Joshi, MD

FOR IMMEDIATE RELEASE

Combination of 2 implanted nerve stimulators dramatically improves quality of life for those who have had poor results from back surgery

CHICAGO – April 22, 2008 – Help is on the way for patients who have undergone back surgery but who continue to suffer from chronic pain in their backs and legs, thanks to a novel technology pioneered by two Chicago-area pain management specialists.

Called a “hybrid technique,” the procedure combines an implanted electronic device called a dorsal column (spinal cord) stimulator with a newer technology known as peripheral nerve field stimulation (PNFS). This latest development in pain management gives patients drug-free relief from the severe, chronic back and leg pain of failed back surgery syndrome (FBSS), a condition suffered by nearly half of all spine surgery patients.

“Since 1968, physicians have used the dorsal column stimulator to control the leg pain common among patients with FBSS, but it does little to relieve back pain,” explains Eugene G. Lipov, MD, Director of Pain Research at the Northwest Community Hospital, Arlington Heights, Ill. “Recent studies have shown that peripheral nerve field stimulation is very effective in relieving back pain. This is what led us to combine these two technologies. Patients can have the best of both worlds: relief from leg and back pain they can’t get even with the strongest pain medications.”

Narcotics, such as codeine and morphine, don’t work well on nerve pain, which tends to be opiate-resistant. Implantable dorsal column stimulators stop pain signals from reaching the brain. Peripheral nerve field stimulation is a newer technology that is more focused on shutting off pain signals further away from the spinal column. Used together, the dorsal column stimulator and peripheral nerve field stimulation effectively block the body’s pain signals from the legs and back to the brain.

Performed as an outpatient procedure, the hybrid stimulator is implanted subcutaneously (under the skin) in the abdominal wall, side of the back, or in the upper hip area. It is approximately the size of a small cell phone. Typically, three electrical leads connected to the stimulator unit are then implanted in areas of the lower back and leg where the patient has felt the most pain. The patient is then able to control his or her pain by placing a small remote control device over the implanted stimulator. Patients feel their pain replaced by a mild tingling sensation. The hybrid stimulator can be left in place for seven to nine years, at which time a simple surgery is performed to replace the battery only, not the electrical leads.

“Using the hybrid technique we’ve literally seen patients’ quality of life dramatically improve right before our eyes,” says Jay R. Joshi, MD, Dr. Lipov’s research partner. “We have been able to offer hope and significant success to patients who have failed virtually every other treatment, including surgery, spinal injections, physical therapy, and medications. Many of our patients no longer need pain medications, and they quickly return to work and to the activities of daily living pain-free. It is a tremendous cost savings in terms of insurance claims, lost productivity at work, and offers patients an alternative to potentially addictive pharmacologic treatment.”

In 2005, there were 34 million physician visits for back-related symptoms, according to the National Center for Health Statistics. A review article published in The Journal of the American Medical Association earlier this year estimated an $85.9 billion was spent in treating spine problems in 2005, with the greatest cost increase coming from use of prescription pain medications. “Clearly, this is an enormous problem for Americans, physically, emotionally, and economically,” Dr. Lipov says. “But we believe this new procedure will restore quality of life to millions of patients who suffer from back and leg pain and who have not found relief from surgery or drug treatment.”

Drs. Lipov and Joshi have implanted the hybrid stimulator in 19 patients since August 2007. Patients report 60% to 100% reduction in pain using the stimulator; to date, no patients have had the hybrid stimulator removed. Lipov’s and Joshi’s findings will be presented at the American Society for Stereotactic and Functional Neurosurgery conference in Vancouver, British Columbia, Canada, in June.

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