Treatment  of  Neuropathic  Pain  by  Intra   -  Muscular  Stimulation 

 (Published in The Journal of the Australian Medical Acupuncture College, Vol 21, No 1, 2005)

 

ONG  TOO  FAFP

Family  Physician   in  Private  Practice

19D,  Lebuhraya  Batu  Lancang

Taman  Seri  Damai

11600  Penang

Malaysia

 

                     

Summary

 

 

Objective  :    To  assess  the  effectiveness  of  Intra   -   Muscular  Stimulation  (  IMS  ) in the  treatment  of   Neuropathic  Pain   (  NP  )

 

 

Method      :  200  Patients  with  NP  at  different  regions  were  examined  and  treated by   Gunn’s  IMS  Technique. 

 

Results        : 64% of patients observed achieved moderate to excellent pain reduction as measured by the visual analogue score; 60.5% of the patients regained moderate to excellent functional improvement at the end of the study

 

 

Conclusion  :  IMS  is  an  effective  method  in  the  treatment  of  NP.

 

 

Key  words  :  Neuropathic  Pain,  Intra-Muscular  Stimulation,  Law of Nerve Denervation.

      

Introduction

 

Neural injury or malformation causes NP. The population prevalence in the US is approximately 2.4%, increasing with age to 8%. NP responds poorly to opioids and non-steroidal anti-inflammatory drugs. Drugs such as amitriptyline, carbamazepine and gabapentin have been used with some success but the outcome of treatment is unpredictable while relapses are frequent and side effects are common.

 

Professor C. Chan Gunn of Vancouver developed the IMS technique for the treatment of NP. This method has been successfully practiced in many pain centres worldwide, eg Institute for the Study and Treatment of Pain, Vancouver and the Multidisciplinary Pain Centre, Washington University, Seattle.

 

200 chronic pain patients of neuropathic origin who had failed to respond to various forms of medical and/or surgical therapy were treated using the IMS technique. The duration of treatment was 6 months from the 5th of October 2002 to the 4th of April 2003.

 

The outcomes of the response to the IMS technique were analysed and discussed.

 

Subjects  and  Methods

 

 

 Number  of  Subjects   :  200  patients

 

 

Sex                                    :   Female             :  127  patients

                                               Male                  :   73   patients

 

 

 

Age   Group                    :   From  28  years  to  85  years

                                              Mean  age          :  54.2  years

 

 

 

Age in years

21 to 30

31 to 40

41 to 50

51 to 60

61 to 70

71 to 80

>80

Number of patients

 

2

 

36

 

48

 

49

 

 

40

 

17

 

8

 

 

Presenting   Symptoms                                                           Number  of  Patients

(  Regional  pain  )

 

 

Neck   Pain   (  N  )                                                                                    22

 

 

Neck  Pain  &  Upper  limb  pain                                                              55

(  N  +  UL  )

 

 

Backache   (  B  )                                                                                        40

 

 

Backache  &   Lower  limb  pain                                                                56

(  B  +  LL  )

 

 

Neck  &  Upper  limb  pain   (  N  +  UP  )                                                   7

Backache  &  Lower  limb  pain  (  B  +  LL  )

 

 

Upper  limb  pain  &  Lower  limb  pain                                                     16

(  UL  +  LL  )

 

 

Chest  pain   (  C  )                                                                                         1

 

 

Heart  pain    (  H  )                                                                                        1

 

 

Gastro-intestinal  tract  pain  (  GIT  )                                                           2 

 

 

 

Duration  of  Pain

 

 

Duration of pain in years

 

<1

 

1 - 3

 

4 - 6

 

7 - 9

 

10-12

 

13-15

 

16-18

 

19-21

 

>22

Number of patients

 

55

 

55

 

33

 

11

 

31

 

2

 

2

 

6

 

5

 

 

Number  of  IMS  Treatments

 

Number of IMS Treatments

 

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 

 

9

 

10

 

11

Number of Patients

92

37

29

25

6

4

2

2

0

1

2

 

Manifestations of Neuropathy were identified and elicited

 

 

Sensory  System          :   Hyperpathia  ,  Allodynia  ,  Hyperalgesia  ,  Dysesthesia

 

 

Autonomic Signs         :   Vasomotor     :  Vasoconstriction  ,  Coldness

                                          Sudomotor     :  excessive  sweating

                                          Pilomotor       :  Cutis  anserinus  (  goose  -  bumps  )

                                          Trophedema   :  local   subcutaneous  tissue  oedema.

                                                                    Match  -  stick  test  positive.

                                          Trophic  changes  in  skin  or  nail  ,  eg.  Hair  loss.

                                           

 

Motor  System            :   Muscle shortening   :   Ropey   band

                                                                              Limitation  of  Joint  Range

 

                                          Enthesopathy          :   thicken  tendinous  attachment 

                                                                              to  bone.

 

 

NP  was  diagnosed  when  the  above  symptoms   and  signs  were  present. 

The  involved  segments  were  identified  both  in  the  territories  supplied  by  the 

anterior  and  posterior  rami  of  the  peripheral  nerves.

 

Methods                      :     The  areas  to  be  needled  are  cleaned  with  surgical  spirit. The  points  of  needle  insertion  were  located  at  the                                                              muscle motor  points  or  musculo – tendinous  junction.

 

                                           The  IMS  needle  is fixed  to  the  plunger  and  inserted perpendicular  to  the  skin.  A grasp  was  felt  when  the 

                                           muscle  contracts.  Manual  manupulation  of  the needle intensifies  the  contraction  of  muscle  but  subsequently

                                           relaxes  the  muscle  more  quickly.  A  neurometer  is sometimes  used  to  help  relax  the  muscle.  The needle  is

                                           removed  when  the  muscle  is completely  relaxed.   

 

Analysis                       :    Visual  analogue  score  was  used  for  pain  measurement.  

 

Results

 

Pain  Reduction

 

 


 

 

 

 


0  %                             :  No  Reduction

1  %    -    25 %           :  No  Significant  Reduction

26%    -   50 %            :  Mild  Reduction

51%    -   75 %            :  Moderate  Reduction

76%    -  100%            :  Good  to  excellent  Reduction

79  patients    (  39.5%   )  had moderate  (  51%  -  75%  )  pain  reduction

49   patients    (   24.5%  )  had  good  to  excellent  (  76%  -  100%  )  pain  reduction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 

    0  %                   :  No  improvement

    1  %  -  25  %    :  No  significant  improvement

    26%  -  50  %    :  Mild  improvement

    51%  -  75  %    :  Moderate  improvement

    76%  -  100%    :  Good  to  excellent  improvement

 

 

34  patients  (  17%  )  achieved  moderate (  51%  to  75%  )  functional  improvement  

 

87  patients  (  43.5%  )  achieved  good  to  excellent (  76%  to  100%  )  functional    improvement

 

 

Patient Response to IMS

 

 

Right Leg, Fabere Sign : Positive, before treatment

Right Leg, Fabere Sign : Negative, immediately after           one (1) IMS treatment

 

 

 

 

 

Left arm, Abduction <90 degrees before treatment

Left Arm, Full abduction after five (5) IMS treatments

 

 

      Discussion

 

Pain  is  defined  by the  International  Association  for  the  Study  of  Pain  (  IASP  ) as  “an   unpleasant  sensory  and  emotional  experience  associated  with  actual  or  potential  tissue  damage  or  described  by  the  patient  in terms  of  such  damage.”

About  10%  of  all pain patients  continue to have pain lasting  for  more than 3  months, i.e. chronic pain.  The majority  of  chronic  pain  patients  are  in  fact  suffering  from  neuropathic pain.

 

 

Cannon  and  Rosenblueth’s  “  Law  of  Denervation  Supersensitivity  ” , Described  in  the  1940s  explains  the  mechanism  of  NP.  It  states  that  “  when  a Unit  is  destroyed  in  a  series  of  efferent  neurons  ,  an  increased  irritability  to  chemical  agents  develops  in  the  isolated  structure  or  structures  ,  the  effect  being  maximal  on  the  part  directly  denervated .”  All  denervated  structures  develop  supersensitivity  including skeletal  muscles ,  smooth  muscles  ,  spinal neurons  ,  sympathetic  ganglia  ,  adrenal  glands  &  brain  cells.  Cannon  and  Rosenblueth’s law was  based  on  work showing that total  denervation  and  decentralization  is required for  the development of supersensitivity.  But  we  now know  that  any  disturbance  to  the  flow  of  impulses over  a  period  of  time  is sufficient to  cause  disuse  supersensitivity.

 

 

The  most  common  cause  of  NP  is  due  to  degeneration  of  spine,  ie . .Spondylosis.   This  process  irritates  the  nerve  roots  and  cause  “shortening Muscle  Syndrome”  or  visceral  complains.  Muscle  shortening  strains  its  attachments  resulting  in  tendonitis  or  epicondylitis.  This upsets the  alignment  of the  joint,  causes  arthralgia  and  bony  spur  formation.  In  addition  it  increases  the tension  between  spinal  joints  giving  rise  to  “ Facet  Joint  Syndrome ”. 

Neuropathy  also  degrades  the  quality  of  collagen  tissue  which  weakens  the  joint.

 

 

In  IMS,  when  a  needle  is  inserted  into  the  muscle  ,  it  gives  rise  to  an  outburst  of  injury  potential  which  relaxes  the  shortened  muscle.  This  intrinsic  source  of  energy  known  as  the ‘  Current  of  Injury  ‘  also  heals  the  damaged  nerve.  Needling  cause  minute  injury  and  bleeding  in  the  tissue  which  promotes  healing  by  releasing  platelet  derived  growth  factor  (  PDGF  )  from  the  blood.

 

 

My first  200  patients  with  NP  were  treated  with  the IMS  technique  ,  64%  of  them experienced moderate  to  excellent  pain  reduction  and  60.5%  of  them  achieved  moderate  to  excellent  functional  improvement.  2  patients  with  Irritable  Bowel  Syndrome  were  cured  with  IMS  suggesting  that  IBS  may  be  caused  by  neuropathy.  Till  today ,  treatment  of  NP  with  drugs and / or  surgery  has  been  disappointing.  From  my  study  ,  I conclude that  IMS  is  an  effective  and  safe  mode  of  therapy  for  neuropathic pain. 

 

Key Learning Points

 

1)     Neuropathy causes denervation supersensitivity which results in muscle shortening.

2)     Neuropathy can be easily diagnosed with clinical manifestations

3)     Nerve segmental involvement must be correctly identified

4)     IMS is an effective treatment of neuropathic pain

 

Acknowledgement

 

 

I am forever indebted to Professor Gunn Chit Chan for teaching me IMS.

 

References

 

 

1        .   C. Chan  Gunn .  The  Gunn  Approach  to  the  Treatment  of  Chronic  Pain, 2nd   Edition  ,  2002.  Churchill  Livingstone.

 

 

2        .   C.  Chan  Gunn  ,  W.E.Milbrant  ,  A.S.Little  ,  K.E.Masaon  ;  Dry  Needling of  Muscle  Motor  points  for  Chronic  Low  Back  Pain  ;  Journal  Spine, Vol  6  ,  Number  3  ,  May  1  June  1980.

 

 

3        .   C.  Chan  Gunn  ,  W.E. Milbrandt  ;  Low  Back  Sprain  ,  Journal  Spine, Vol  3  ,  Number  3,  Sept.  1978.

 

 

4        .   C.  Chan  Gunn  ,  “  Prespondylosis  “  and  some  Pain  Syndrome  following Denervation  Supersensitivity.  Journal  Spine  ,  Vol  5  ,  Number  2  ,  March  /  April  1980.

 

 

5        .   C.  Chan  Gunn  ,  Neuropathic  Pain  ;  Annals  of  the  Royal  College  of  Physicians  of  Canada.  Vol  22  ,  No.  5  ,  July  1989  ,  p.  327 – 330.

 

 

6        .   C.  Chan  Gunn  ,  A.E.Sola  ,  J.D.Loeser  ,  C.R. Champman  ;  Dry  Needling  for  Chronic  Musculoskeletal  Pain  Syndromes  ;  The  Scientific International   Journal  ,  Vol  1  ,  No.  2  ,  Summer  1990.

 

 

7        .   W.B..Cannon  ,  A.Rosenblueth  ;  The  Supersensitivity  of  Denervated  Structures   -   A  Law  of  Denervation  ;  1949  ,  The  MacMillan  Company, New  York.

 

 

8        .   W.Janig  ,  R.Baron  ;  Complex  Regional  Pain  Syndrome, The  Lancet  Neurology  Vol  2  ,  Nov  2003  ,  p.  687  -  696.

 

 

9        .   H.L.Fields  :  Peripheral  Neuropathic  Pain  ;  Pain  Management  edited  by  R.Melzack  ;  P.D.Wall  2003  ,  Church  Livingstone  ,  p.  581  -  589.

 

 

10   .   C.  Chan  Gunn  :  Review  :  Mechanical  Manifestation  of  Neuropathic  Pain Annual  of  Sport  Medicine  ,   5  :  138  -  141  (  c  )  1990  AMAA California  and  AASP  ,  Connecticut.

 

11   .   C.  Chan  Gunn  :  Treating  Myofascial  Pain.  The  AAMA  Review, Fall  /  Winter  1991  ,  Vol  3,  No.  2.

 

 

12   .   C.  Chan  Gunn  :  Radiculopathic  pain  :  Diagnosis  and  Treatment  of Segmental  Irritation  and  sensitization  ,  Journal  of  Musculoskeletal, Pain  ,  Vol  5  (  4  )  ,  1997.