When Treating Persistent Pain, Bring the Brain into the Treatment

LAS VEGAS—Can a patient who has had complex regional pain syndrome (CRPS) for 6 years become pain-free?

If you engage the patient’s brain in treatment to reset the neuroplastically altered persistence of the pain, the answer is “yes,” said Michael H. Moskowitz, MD, MPH, Assistant Clinical Professor Department of Anesthesiology and Pain Medicine University of California, Davis, School of Medicine, Davis, and Bay Area Pain Medical Associates, San Francisco.

Dr. Moskowitz presented the case of LB, a 31-year-old woman with CRPS that began as repetitive strain injury of her wrists and arms from working as a chef. She awakened from surgery for tendonitis with severe pain, temperature intolerance, and touch and mechanical allodynia. When Dr. Moskowitz first saw her in May 2011, she was spending almost all of her time at home alone.

Over the course of following 2 years, the patient stopped using hydromorphone, gabapentin, topiramate, lidocaine patches, trazodone, and lorazepam; no longer used pillows and blankets for cold intolerance; and no longer protected her personal space. Her CRPS symptoms and signs disappeared and she is pain-free, working as a doula and retraining as a nurse-midwife. Finally, not only is she not fearful of her pain, she is traveling, has gotten married, and is pregnant.

This was accomplished by shrinking the pain map by flooding the nine areas of the brain where pain is perceived using thoughts, images, sensations, memories, soothing emotions, movement, and beliefs, Dr. Moskowitz said. These nine areas are the amygdala, insula, prefrontal, anterior cingulate, supplementary motor, somatosensory 1 and 2, posterior parietal, and posterior cingulate, all of which process not only pain but are responsible for empathy, posttraumatic stress, and memory retrieval, for example.

Practically, this means shifting the “passive chronic pain patient” to an “active person, counter-stimulating pain,” he said. The goal of the current state of pain treatment is to maintain patients with a lower level of pain, improved function, and improved quality of life. In reality, “we settle for far less—some constant lower pain level with flares that require more acute intervention,” he said.

The new paradigm is relentless treatment targeting the dynamics of persistent pain, in which patients move through four phases—rescue, adjustment, functionality, and transformation (RAFT)—as they become more resilient, he said.

This shifts the emphasis from doing something to the patient to partner with the patient, with the goal of disconnecting excessively connected pain networks using the same principles that created them.