contents society pub 2012...she was born in te hapua, educated at queen victoria college and...

Ngau MamaeQuarterly Publication of the New Zealand Pain Society Instructions to AuthorsNgau Mamae aims to keep clinicians up-to-date in regard to pain diagnosis and management. It will inform on NZ Pain Society (a Chapter of IASP – International Association for the Study of Pain) initiatives and activities. The Editor and Sub-editors seek contributions that will further these aims. Articles, reviews and letters should be submitted by email or supplied on disk to:

EditorDr John Alchin Pain Management Centre, Burwood Hospital, Christchurch [email protected]; or [email protected]

Assistant EditorAndrew Fairbairn Pain Management Centre, Burwood Hospital, Christchurch [email protected]

Sub-editors — Contact DetailsMs Kate McCallum (Nursing) [email protected]

Dr Mike Butler (Medicine) [email protected]

Dr Jurriaan de Groot (Rehabilitation Medicine) [email protected]

Mr Murray Hames (Physiotherapy) [email protected]

Dr Sandy MacLeod (Palliative Care) [email protected]

Mrs Jeannette Shennan (Psychology) [email protected]

Graphic DesignRadiate Design p: 03 385 [email protected]

TextWe require single spaced typescript, Times New Roman, size 12 font (Word-compatible software where possible). Please write as concisely as possible and include a word count. Subheadings should be used to divide the text. Please underline at least three or four interesting sentences or quotes from the article that could be enlarged to draw attention to the piece. Note that not all of them will necessarily be used. Authors’ names with their professional qualifications job title and affiliation should appear below the article title. Generic names should be used for drugs; if necessary, brand names may follow in brackets.

Literature References References cited in the text should be included in parentheses and should be by author(s) and year in chronological not alphabetical order. Papers written by two or more authors are cited in the text using the abbreviation ‘et al.’ using the name of the leading author, even if the subsequent authors are not the same in all references. All references used in the text must be listed at the end of the paper and arranged alphabetically by author. References must be complete, including initial(s) of author(s) cited, title of paper referred to, journal, year of publication, volume and page numbers. If more than two references with the same year and author(s) are cited, use lowercase letters after the year (Melzack et al. 1984a,b). Journal titles should be abbreviated according to Index Medicus, List of Journals indexed, latest edition. For citations of books the following sequence must be maintained: author(s), title of article, editor(s), complete title of book, place of publication, publisher, year and page numbers.

ExamplesPennebaker JW. The psychology of physical symptoms. New York: Springer, 1982.

Philips H. Avoidance behaviour and its role in sustaining chronic pain. Behaviour Research Therapy 1987a; 4: 273-279.

Philips H. The effects of behavioural treatment on chronic pain. Behaviour Research Therapy 1987b; 5: 365-377.

Scharloo M, & Kaptein A. Measurement of illness perceptions in patients with chronic somatic illness: a review. In: Petrie K, Weinman J, editors. Perception of health and illness. The Netherlands: Harwood Academic Publishers, 1997. pp. 103-154.

Photos, Graphics and IllustrationsGraphs and diagrams can either be passed on as hard copies so that they can be scanned or they need to be at 300dpi and at approximately postcard size. Files can be accepted in the following formats: jpg, tiff, pdf and eps.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted by means of electronic, mechanical, photo-copying, recording or otherwise without prior consent of the publisher. © New Zealand Pain Society Incorporated 2005.

Ngau Mamae (Real Pain) Ngau means to bite or engage in a very real way. Mamae means pain. In combination, the words describe a very real and deeply ingrained, gripping, biting pain.

— Meri Meri PenfoldOf Ngati Kuri descent from the Far North. She was born in Te Hapua, educated at queen Victoria College and qualified as a teacher working in education for many years. Moved to the Maori Studies Department at Auckland University. She is officially employed by the University to provide Maori as an advisor and in particular provides Maori interpretations for course titles and official documents etc.

Photo: Amanda Sinclair

Contents2 Editorial Dr John Alchin

5 President’s Corner Dr Ross Drake

6 Members Profile Natalia Valentino

7 Medical shockwaves for the treatment of peripheral neuropathic pain in a Type II diabetic: a case report Kenneth Craig, Marjorie Walker

17 IASP Matters Michael Nicholas

18 NZPS Research Working Group

21 Education Working Group Report

22 NOI Neurodynamics and the Neuromatrix Conference: Adelaide, April 2012 Louise Sheppard

24 NZPS Council Members 2012 – 2013

25 Registration Form for New Membership

2 NGAU MAMAE Winter 2012

EditorialDr John AlchinPain Management Centre, Burwood Hospital, ChristchurchThe comments in this Editorial do not necessarily reflect those of the NZ Pain Society or its Executive; nor of my employer, the Canterbury District Health Board.

Firstly, you may have noticed – and perhaps been pleasantly surprised at – the arrival on time of this Winter edition of Ngau Mamae. Credit for that goes to Andrew Fairbairn, a physio-therapist colleague at Burwood Hospital, who has very kindly agreed to become assistant editor. His organisational skills, exercised in the most pleasant of ways, makes up for some evident deficits of the same in me. So thank you, Andrew, for taking on this task. Loyal members may now look forward to a return to the regular quarterly publications you were accus-tomed to under my predecessor, Kate McCallum.

Secondly, numerous matters I have come across recently have, in different ways, raised the question of the role of opioid medications in pain management.

Opioids – again

A Lancet Editorial1 commenting positively on “the introduc-tion of independent prescribing of opioid analgesia by appropriately qualified nurses and pharmacists in the UK in April, 2012”, added that the “correct amount of analgesia given at the right time has a considerable positive effect on the quality of life of a patient in palliative care … Prescrip-tion drug misuse should be prevented, but the comfort of seriously ill patients cannot be sacrificed for fear of it. Though some patients may be beyond hope of cure, they are not beyond care. Opioid prescription in such cases is not just medical treatment: it is basic human kindness.”

A recent British Medical Journal (19 May 2012) also had two brief items, both touching on the role of opioids in pain management:

It mentions2 a book first published in 1887 (“Euthanasia3: or, Medical Treatment in Aid of an Easy Death”, by William Munk), that accurately listed long ago the fundamental principles of the use of opioids for terminal pain: opium, “our one trustworthy remedy, must be administered in such doses as will appease suffering and disorder, and in this respect we are to be governed solely by the effect and relief afforded . . . [Its effects] continue for about eight hours, and if its action is to be maintained it should be repeated at intervals of that duration or somewhat less.” That opioids have the key role in managing terminal malignant pain is, or should be, undisputed.

And an Editorial on “Severe human rights abuses in health-care settings”4 is consistent with this: “The preoccupation of officials with drug control at the expense of patient care often translates into insurmountable hurdles to the administration of adequate pain relief. In Ukraine, oral morphine is unavail-able, and arbitrary limits on injectable morphine provide only a small fraction of what patients need. This is contrary to recommendations of the World Health Organization and the International Narcotics Control Board, and UN experts have stated clearly that denial of pain relief constitutes a

failure by governments to protect patients against torture and cruel, inhuman, and degrading treatment. Reasons for such inadequacies include governments failing to ensure effective systems to procure and distribute analgesics and to provide appropriate training, and misplaced concerns about the risk of patients becoming addicted. Indeed, fear of addiction leads some doctors to perform surgery without anaesthesia on patients with a history of drug dependency.”

In the same vein, several years ago an Editorial in The Lancet5 pointed out the striking and very disturbing statistic that, in 2008, over 90% of the morphine consumed globally was by the 13% of the world’s population living in Anglophone Australasia and North America, and the member states of the European Union. In other words, the 87% of the world’s population living in China, South and South-East Asia, Africa, Central and South America, and Russia, have little access to morphine for acute (post-traumatic or post-operative) pain, or for terminal cancer pain.

This is the true global inequity – and iniquity – of access to opioids for pain. It is of poverty (of access to opioids) in the midst of plenty: at the same time as most of the world lacks access to morphine for acute or cancer pain, the USA is in the midst of an epidemic of deaths through overdose of prescribed opioids for chronic non-malignant pain6.

A very good recent article in the popular press highlighted this as a growing problem in New Zealand7, exemplified by the death of a 19 year old Dunedin university student from an opioid overdose. As she was prescribed opioids for chronic back pain, the story is relevant the NZ Pain Society. And her history will sound familiar. She first developed low back pain aged 17, while simply jumping over a creek on holiday. As less powerful analgesics were ineffective, 5 months later her GP first prescribed OxyContin (sustained release oxycodone, a strong opioid analgesic), in her last year of High School. Although surgery for a fractured bone in her spine a year later was judged by the surgeon a success, her pain worsened post-operatively; more on that later. She began injecting oxycodone IV, buying it off the street from a supplier (who had it prescribed: as the article explained, “patients prescribed 20mg a day of OxyContin can sell that amount on the street for about $20, and manage their pain with $5 of cannabis”). Aged 19, just under two years after her pain began, and at the end of her first year at University, she died of an overdose – on top of her IV oxycodone, she snuck some methadone elixir that her mother had just brought home after her own surgery.

The article, although good, has some limitations, including that it is somewhat simplistic, assuming a unifactorial under-standing of drug addiction; eg there is no apparent awareness that drug addiction is not due simply to exposure to poten-tially addictive drugs (eg alcohol, opioids); there also needs to be a potential addict. And here genes are important8,9.

2012 Winter NGAU MAMAE 3

There has to be more than just the exposure, as most of those exposed to addictive substances do not develop drug addic-tion: in much the same way as most of those who hurt their backs do not develop chronic back pain.

The article also did not question the role of surgery in chronic low back pain, although the fact that her pain was worse post-operatively, and that her need for oxycodone did not cease as a result of the surgery, hints at the limitations of surgery for chronic low back pain. Surgery for low back pain is a particular risk in a private health care system, as can be seen from the rates of spinal surgery in the USA10 and Australia11.

The North & South article points out that oxycodone was first registered for use in NZ in 2001, became Pharmac (taxpayer) funded in 2005, and in 2010 out-prescribed morphine for the first time. Oxycodone prescriptions in NZ have quadrupled since 2007, to over 180,000 scripts for oxycodone in 2011, costing NZ$6 million. But, as morphine prescriptions have not reduced proportionately, “thousands of people who were not on strong painkillers before the introduction of oxyco-done are now taking them.” In addition, the NZ Best Practice Advisory Centre’s prescribing guidelines for oxycodone point out that there was no evidence to support the use of oxyco-done ahead of morphine.

The North & South article raises the important issue that opioids may not be the appropriate treatment for chronic non-malignant pain, such as this case of chronic low back pain, quoting Wellington psychiatrist and addiction specialist Dr Jeremy McMinn: “there’s increasing awareness that opioid drugs – like morphine, like methadone, like oxycodone – might not at all be very good for those pains. In fact, they may make the situation worse … you can’t just say, don’t use them in chronic pain, but you can say they appear to have been overused in chronic pain.” He is surely correct. The article also correctly notes that the use of opioids in chronic pain is “a relatively recent phenomenon”.

The possible effect of the withdrawal of dextropropoxyphene, a weak opioid, from the NZ market in June 2010 on the rate of oxycodone was raised, with speculation that “it’s likely that some doctors transferred their patients onto oxycodone, despite it being far more powerful” than the dextropropoxy-phene containing analgesics Paradex, Capadex and Digesic.

Although this is just speculation, it does raise questions about the removal of dextropropoxyphene. Why was this done? And what were the effects?

In December 2009 the NZ Medicines Adverse Reactions Committee (MARC) reviewed the benefits and risk of dextro-propoxyphene-containing medicines, and concluded12 that they “are no more effective than maximum recommended doses of paracetamol alone; have the potential to cause more adverse reactions than paracetamol used at recommended

doses; are more dangerous than other simple analgesics in overdose, particularly when combined with alcohol. Deaths have occurred in association with dextropropoxyphene use in NZ13. Deaths related to dextropropoxyphene overdose have occurred within 1 hour of ingestion and before medical intervention could be obtained”. And “overall the risks of these medicines exceed their benefits.”

Medsafe accepted the MARC’s recommendation that, “in the interests of public safety”, Capadex and Paradex be withdrawn from New Zealand, pointing out that dextropropoxyphene containing medicines had already been withdrawn from the UK and Sweden, and that medicines regulators in Europe and Singapore had also announced that they will be withdrawing these medicines.

Medsafe added that the majority of patients in the UK, after dextropropoxyphene was removed from the market, were successfully transferred to paracetamol alone, codeine alone, or paracetamol/codeine combination products. More of this below.

Later it was removed from the market in the USA and Australia, after the US FDA (Food & Drug Administration) in late 2010 reported new information on the potential for dextropropoxy-phene-containing medicines to cause QT prolongation and life-threatening arrhythmias, based on results of a multiple ascending dose study of the effects of dextropropoxyphene on cardiac conduction. There were also questions related to its safety in the event of accidental or intentional overdose.

Regarding the effects of its removal from the NZ market, one immediate positive effect was that tramadol 50mg immediate release capsules became Pharmac funded, the same day that all dextropropoxyphene containing analgesics were removed from the NZ market (June 2010). This was a sort of trade-off, and in my opinion a good one, as tramadol, a very useful analgesic, was not previously available for most patients due to cost.

However, an unexpected negative effect was that it flushed some interesting and unfortunate cases out of the woodwork – we were referred some chronic pain patients whose pain, for whatever reason, was previously adequately controlled on Capadex and Paradex, but who decompensated when it was no longer available. People we hadn’t seen before, ever, were now referred to us by their perplexed GPs wondering what to try instead, as codeine/paracetamol, DHC, and tramadol, appropriately tried when Capadex and Paradex were no longer available, were ineffective; and their chronic pain patient, previously functioning well, was now having difficulty coping and functioning. I personally saw only a handful of such cases – perhaps 3 or so over the next 6 – 12 months; but they were striking nonetheless. It was a revelation to me. Regulatory authorities such as Medsafe, as quoted above, naïvely assume


that one analgesic is good as another - “if we remove dextro-propoxyphene from the market, patients can just transfer to codeine. No problem.” But what if, despite reassurances, nothing else available suffices for a particular patient? Medsafe and other medicines regulators don’t confront that problem.

On this issue, Dr M. Butler, Rheumatologist/Pain Medicine Specialist at the Auckland DHB, recently commented to me that “certain patients just ‘suit’ certain drugs, and given the complexity of individual body/brain metabolism that is surely no surprise. We need a repertoire of medications for pain.”

The Administrative Appeals Tribunal of Australia also agrees14. In June 2012 they upheld an appeal by Aspen Pharmacare Australia Pty Ltd, the drug company that markets two dextro-propoxyphene products in Australia (Di-Gesic and Doloxene), against the decision of the Minister for Health & Ageing to remove them from the market, pointing out the importance of “balancing the needs of the individual against the benefits at a population level.”

This surely indicates the need for medicines regulators like Medsafe to consider the problems of chronic pain, before deciding to remove analgesics from the market. The first problem of chronic pain that needs to be borne very clearly in mind is the very unpleasantness and unrelenting nature of chronic non-malignant pain. Pain is designed to be unpleasant; if it were not, it would not achieve its roles. So someone living with chronic pain, eg due to malfunction of the nociceptive (“pain”) system, is in a most unenviable position, and deserves all the health care assistance available to try to make their lives less unpleasant. This includes a range of analgesics, due to the varied individual response – good and bad – to medications.

The second problem of chronic pain that needs to be realised is the impotence of currently available treatments15. This unpalatable fact is very widely unrecognised. For example, Goldberg wonders16 “why pain is seriously undertreated in the United States”, as he believes that, “Although some kinds of pain are difficult to treat, we generally possess the technical armamentarium to significantly ameliorate the vast majority of pain experiences. Yet we do not.” This is simply not true – clinical experience unfortunately forces us to agree with Woolf (ref 15), not Goldberg (ref 16).

Chronic pain bedevils the daily life of our patients, and frustrates our daily working life trying to find something that may help ease their pain. So a decision to remove an analgesic from the market may well remove the only medication that a particular patient has found that makes their life tolerable. This is the case with those unfortunate few patients I saw after dextropropoxyphene was removed from the NZ market 2 years ago.

Opioids have an established role – indeed, the central role – in treating both acute and terminal malignant pain. But they do not have a central role in treating chronic non-malignant pain; and indeed their use in this situation is risky, and needs to be very carefully managed.

1. “Pain control – a basic kindness”; The Lancet, June 2, 2012, page 20242. BMJ, 19 May 2012, page 423. In order to avoid confusion, I point out that “euthanasia” in this book

meant, not the hastening of death, but in its original, etymological sense of an easy or pleasant death, ie one not unduly plagued by pain.

4. Guterman L & McKee LM; BMJ, 19 May 2012, page 85. Liberman J et al: “Ending inequities in access to effective pain relief?”;

Lancet, 11 September 2010, page 856-76. In the USA, “Deaths caused by poisoning outnumbered deaths related to

motor vehicle traffic in 2008 – for the first time in at least 3 decades … While the rate of injury-related deaths caused by motor vehicle crashes fell by half between 1980 and 2008 (from 22.9 per 100,000 population to 12.5 per 100,000 population), the poisoning rate has tripled (from 4.8 per 100,000 population to 13.5 per 100,000 population) … There were 41,000 poisoning deaths in 2008, 9 out of 10 of which were caused by medications or illicit drugs. Poisonings involving opioid pain medications appear to be an important driver of these trends, with such analgesic-related poisonings making up 40% of all drug-related poisoning deaths in 2008 compared with only 25% in 1999 … much of this increase has occurred in the past decade, with the number of opioid medication–related deaths tripling from 4000 in 1999 to 14,800 in 2008. Most of these deaths involved such medications as morphine, hydrocodone, and oxycodone.” Journal of the American Medical Association, January 18, 2012, page 42

7. Chisholm, D: “The Accidental Addicts”; North & South; May 2012; pages 42-52.

8. Kendler, KS et al: “Genetic & Familial Environmental Influences on the Risk for Drug Abuse: A National Swedish Adoption Study”; Arch Gen Psych, July 2012; pages 690-97;

9. Li MD & Burmeister, M: “New insights into the genetics of addiction”; Nature Reviews Genetics, April 2009, pages 225 - 31

10. Deyo, RA: “Point of View: In Response to Spinal Fusion in the United States: Analysis of Trends From 1998 to 2008”; Spine: 1 January 2012, page 77: “This analysis of trends in spinal surgery is a welcome update to similar previous analyses … Rates of spinal fusion surgery continue to rise at a rapid pace, unabated from previous decades. Increases in fusion surgery easily outpaced those of other orthopedic procedures and common coronary artery interventions … Rapid increases in average charges per operation accompanied increasing rates of fusion surgery. The rapid increase in the national bill for spinal fusion – almost 8-fold in a decade – was the result of both increasing volume and costs per operation. The resulting national bill of $33.9 billion in 2008 is attention grabbing”.

11. Harris, IA & Dao, ATT: “Trends of spinal fusion surgery in Australia: 1997 to 2006”: ANZ J Surg, 2009, pages 783–788: “There is a disproportionately high rate of lumbar spine fusion surgery performed in the private sector, given the rate of private insurance.”

12. A summary of the MARC’s discussion on dextropropoxyphene is included in the minutes of the December 2009 meeting, available on the Medsafe website http://www.medsafe.govt.nz/profs/adverse.asp.

13. Reith D et al: “Opioid poisoning deaths in New Zealand (2001-2002)”; NZMJ 2005; 118(1209): U1293.

14. Details at http://www.austlii.edu.au/au/cases/cth/aat/2012/362.html15. Woolf, C: “Review: Overcoming obstacles to developing new analgesics”;

Nature Medicine (Supplement); 16,11: 1241 – 47; November 2010: “Most existing analgesics for persistent pain are relatively ineffective, have a high side effect burden or abuse liability and, more important, do not reduce pain in all treated individuals. … the number of patients who are needed to be treated (NNT) to achieve 50% reduction in neuropathic pain in one patient is more than four, a high cost for the 3 unsuccessfully treated patients and their physicians”.

16. Goldberg, DS: “Job and the Stigmatization of Chronic Pain”; Perspectives in Biology & Medicine, Summer 2010: pages 425–38:


President’s CornerDr Ross Drake

The Annual Scientific Meeting in Wellington was a resounding success, and sincere congratulations are passed on to the organising committee for their efforts in making it so. The conference theme “A Head of Pain” interacted nicely with the IASP’s global year focus on headache, and all things cerebral were inspiringly communicated by the keynote speakers.

I have no doubt that all participants will have a deeper understanding of placebo and nocebo mechanisms and how cutting edge scanning techniques are helping to unravel the mechanisms behind chronic pain after listening to Dr Serge Marchand and Dr Irene Tracey, respectively. Dr Lance McCracken was captivating in his presentations emphasizing the use of Cognitive Behavioural and Acceptance and Commitment Therapy. Throw into the mix consistent, high quality presentations from local experts and voila! an accomplished meeting. The appetite is whetted for Hamilton in 2013.

Wellington is a city with a predilection for a changeable climate and blustery weather. What more appropriate setting then for the winds of change to blow through the Society at the Annual General Meeting. The considerable work done on the Society’s constitution over the past two years by the Council, in particular Jenny Sandom, came to fruition with acceptance of a new look constitution.

The other major transformation was the election of a fresh Council following the requisite retirement of long serving members Judy Leader, Sue King and Trevor Cook. The support they have provided to the Society for the past decade or more has been unfaltering, and their inspiration for an innovative direction for the Society invaluable in positioning it to become a more vital organisation into the future. A warm welcome is extended to the newly elected Council – President-elect (Brigitte Gertoberens), Secretary (Natalia Valentino), Treasurer (Jenny Sandom), Ngau Mamae Assistant-Editor (Andrew Fairbairn), and new members of council (Catherine Swift and Gwyn Lewis). They join the incumbent President, Editor-in-Chief of Ngau Mamae, and current council members John Spiers and Bronwyn Thompson.

The institution of the first Special Interest Group (Pain in Childhood) was carried unanimously and, as of writing, the number of paid up members was creeping toward the magical mark for formal recognition. The AGM also officially accepted committees for research, education, an annual scientific meeting committee and an advocacy committee. The latter group will be formed as soon as interested members can be drawn together, and the first order of business will be to define a steady and achievable strategy to gain improved political recognition of pain in health policy.

The final act of the meeting was to discuss and vote on an alteration in membership fees. A robust democratic process ensued on the proposed fee structure, with the result being agreement on the following fees to be introduced in 2013.

Gross Income of < $100,000 $75.00 (GST inclusive) Gross Income of ≥ $100,000 $150.00 (GST inclusive) Student $25.00 (GST inclusive) Retiree $25.00 (GST inclusive) Corporate Membership $5,000.00 (GST inclusive)

The Society’s attitude is changing and this change is, perhaps, best illuminated by a quote from the writings of influential Chinese writer and inventor Lin Yutang, “Hope is like a road in the country; there was never a road, but when many people walk on it, the road comes into existence”.


Members ProfileNatalia Valentino

Even as a student of Vladivostok Medical School, she was more interested in why people get sick than how to fix already sick people. She worked for four years at the Far East Academy of Sciences researching the active ingredients and health benefits of some native herbs, including Siberian Ginseng. And after she completed her doctorate in Biological Chemistry (lipid biochem-istry), Natalia took up a teaching role with second year medical students.

After immigrating to New Zealand in 1996, Natalia studied nutritional medicine and infra-red low-intensity laser therapy, which is popular in Russia, Japan, France and some other European countries. In her Auckland clinic, Natalia was treating patients focusing on nutrition and exercise, and used her laser to relieve pain and decrease inflammation in patients with musculoskeletal conditions.

After years of practising and teaching nutrition and biochemistry at the South Pacific College of Natural Therapies in Auckland, Natalia moved to Wellington where she worked in tertiary education, moderating assessments for NZQA and designing a new tertiary degree for Whitereia Polytechnic.

In her current role with Arthritis New Zealand as Service Development Manager, Natalia’s main focus is on encouraging and facilitating self-man-agement for people with arthritis. The main priorities of Arthritis New Zealand are patient education, and advocacy for better services and funding research in the area of arthritis.

Natalia is leading a team of Arthritis Educators who deliver individual and group education, focusing on pain man-agement, joint protection, and exercise, to improve health and well-being of people affected by arthritis. Last year

Natalia is Russian-born. Her mother was a doctor, and the expectation was that she would follow in her footsteps, which she did.

Natalia joined the New Zealand Pain Society, and became secretary in 2012.

Natalia believes in a multi-disciplinary approach and partnerships with other health and community organisations – “We need to work together to provide the best information and education to patients, and support them to achieve better health outcomes.”

When Natalia is not in career mode, she is finding time for her granddaughter and her many hobbies: acting, belly dance, singing Russian songs, travel, organising and facilitating fun events.

Winter 2012 NGAU MAMAE 7

Introduction. Neuropathic pain is a condition that emanates from multiple etiologies where the specific cellular and molecular mechanism of this syndrome has not been fully elucidated, and remains a clinical challenge to manage. Neuropathic pain is associated with disability, quality of life impairment, and emotional stress. Current treatments for patients suffering from neuropathic pain mainly involve the use of pharmacogenics targeted at pain modulation.

Case Background. 43 year old female with a 15 year history of Type II diabetes was referred to our clinic for chronic bilateral heel pain. The incapacitating pain had caused severe functional limita-tions resulting in the loss of employment. The patient had failed to respond to physical therapy, customized foot orthoses, anti-inflammatory drugs, analgesics and several courses of cortisone injections. Gabapentin was effective in providing relief but was ill tolerated by the patient and discontinued. Ambulation and weightbearing was severely restricted and extremely painful, which simultaneously caused emotional distress.

Intervention. Customised foot orthoses and forms of analgesics and anti-inflammatory medica-tion were ceased prior to treatment commencement and remained discontinued throughout the follow-up period of 32 weeks. Three sessions of focused low-intensity medical shockwaves (Li-MST) of 1400 impulses were applied at one week intervals at energy flux density levels ranging from 0.11 – 0.17 mj/mm². Concurrent therapy included the utilization of an over the counter shockstop insole at week 3.

Main outcome measures. Pain, function and emotional measures were performed utilizing pre-treatment and post treatment visual analogue scale (VAS), Neuropathic Pain Diagnostic Questionnaire (DN4), and Pain Outcomes Profile (POP) questionnaire.

Results. Reduction in pain symptoms was significant from pre-treatment VAS scores of 9.5/10, to a score of 1 - 2 at weeks 3, 12, and 24. VAS score at week 32 was recorded at 0.5/10 bilaterally. Pre-treatment DN4 scored as 5/10, was score as 0/10 post intervention. Emotional disposition and outlook were markedly more positive with visible improvements in energy levels and motivation.

Conclusion. Li-MST may provide a novel non-invasive, and non-pharmacogenic disease-modifying treatment for certain neuropathic pain conditions. The low number of treatments and the non-systemic nature of this treatment warrants further research to determine the role of Li-MST in this area.

Keywords: complex pain, dysfunctional pain, neuropathic pain; shockwave therapy, diabetes.

Kenneth CraigSpecialised ESWT Provider, Kompass Health Associates, [email protected]

Marjorie WalkerResearch Assistant, BHSc. Kinesiology, Undergraduate BHSc.(Physiotherapy)

Medical shockwavesfor the treatment of peripheral neuropathic pain in a Type II diabetic: a case report

Editor’s Comments“I very much enjoyed reading the following paper. The authors have not only presented an interesting and worthwhile case; they have done so with skill and flair. Although the physics of the therapy used (low-intensity medical shockwave therapy) is beyond me, that is less relevant when one reflects that we do not really know how most effective therapies do in fact work: the mode of action of an effective therapy is of much less moment than that it is effective. The authors have well-referenced their paper, with a reference list that includes important and up-to-date papers. So there is scope for those interested to further pursue information about this treatment. As the authors corrrectly point out, a case study does not establish a treatment as effective. Rather, it raises questions, and asks for trials to study it more rigorously. As we know only too well, many treatments that seem impressive on the basis of anecdote, a case study or a case series, prove ineffective when tested by the standard of a double-blind placebo-controlled randomised controlled trial. But some do turn out to be effective.”


Introduction

Pain is a highly subjective conscious experience where the noxious nociceptive stimulus influ-enced by pathology, cognitive factors, genetics, memory, and emotion, is interpreted and trans-lated in the cerebral cortex. Neuropathic pain is dissimilar to nociceptive pain where the later is propagated by the physiological stimulation of nociceptive potential or tissue injury, the former arises as a consequence of neuronal lesion or pathologic syndromes of the somatosensory system. (7,14,15,29,34) Nerve damage may occur at any point, of the periphery, or at the cortical neurons in the brain, and can occur synergistically. The specific mechanism of neuropathic pain is yet to be fully elucidated, and presents a clinical challenge as it is often more severe and less responsive to conventional phamacotherapeutics, and can coexist with nociceptive pain. (11,12)Commonly seen contributory factors of neuronal lesions and somatosensory syndromes that give rise to neuro-pathic pain include: metabolic disease, autoimmune disease, vascular disease, trauma, infection, and cancer. (7,29) Notable symptoms associated with the neuropathic episode include: attacks of pain without apparent provocation, hyperalgesia, allodynia, paresthesia, dysesthesia, and sensory deficits, with the latter being a negative sign for neuropathic pain. (2,7,29)

Figure 1. Adapted from the 2008 IASP task force definition. All forms of pain amplification including the lowering of pain threshold are classified under the umbrella term hyperalgesia. This includes cases where the distinction of low or high sensory threshold fiber involvement is unknown.T0 refers to normal pain threshold, and TS (red region) refers to pain threshold after sensitization.

Multidimensional degrees of sensory and behavioral aspects of the neuronal assembly, signaling, and activation are expressed by the pain perception, movement patterns, and emotional dispo-sition of patients suffering from neuropathic pain syndromes (e.g., hyperalgesia, allodynia, fear avoidance, sleep disruption, and depression). Hyperalgesia is classified as an exaggerated sensory reaction to a normally painful stimulus due to high threshold (HT) fiber activity (Figure 1), while allondynia is classified as an exaggerated sensory reaction to a non-painful stimulus, due to low threshold (LT) fiber activity (Figure 2).

Figure 2 Adapted from the 2008 IASP task force definition for allodynia, where pain is clearly induced by low threshold fibers. T0/S refers to the normal threshold for touch sensation which is identical to (or near the stimulation threshold for allodynia.

This case-study reports on the exploratory use of low-intensity medical shockwave therapy (Li-MST) for the treatment of chronic neuropathic pain in a Type II diabetic patient.


Case ReportA 43 year old women made redundant due to pain related dysfunction was referred to our clinic. Region of complaint was diffused around the foot and ankle region. Patient had a 15 year history of Type II diabetes with a reported plasma glucose concentration level of 7.2 mmol/L, controlled with metformin HcI. twice daily, and long acting insulin glargine, once daily. The patient was simultaneously being treated for hypertension, hypercholesterolemia, and peptic ulcers. Medical history associated with this complaint included: rest, ice, physiotherapy, customised foot orthoses, cortisone injections, non-steroidal anti-inflammatory drugs (NSAID’s), and gabapentin. Gabapentin was successful in providing pain relief however was ill tolerated and was discontinued. The result of prolonged inactivity had simultaneously caused an increase in adiposity, and emotional stress due to both the pain experience and the loss of employment.

AssessmentThe patient’s chief complaint was a 14 month history of bilateral heel pain after landing awkwardly from jumping over earthworks on her driveway. Pain was noticed after several weeks, with the right heel being the more severely affected. The patient reported being unable to spend more than 10 – 15 minutes on her feet and even sedentary ambulation was unbearable. Pain symptoms were exacerbated with ambulation and in static weight-bearing, with the worst symptoms experienced after activity. Symptoms were described as sharp unbearable pain upon ambulation and weight-bearing, with persistent dull burning, and the occasional electric-shock like sensation shooting up the ankle and leg bilaterally. Persistent dull burning and electric shock like sensations were present, but to a lesser degree prior to the inciting trauma. Region of discomfort was diffused and experienced inferior to the tarsal tunnel, the distal aspect of the medial calcaneal tubercle, and the medial proximal region of the medial longitudinal arch (PMLA). Neuropathic Pain Diagnostic Questionnaire (NPDQ-DN4) was scored as a 5/10, being diagnostic of neuropathic pain. (6) The patient’s foot type was neutral with mild end range joint motion restrictions occurring bilaterally at the 1st metatarsal phalangeal joint (MTPJ). There was visible favoring of the right foot as was barely able to make ground contact. Visual examination of both feet was unremarkable except for; mild swelling and redness present at the plantar heel which was more pronounced in the right foot. Gait was restricted and slow due to pain with obvious fear to weight-bear and ambulate. Basic neurovascular assessments were unremarkable bilaterally (Table 1). Achilles tendon reflex of the right ankle was unascertainable due a hyperalgesic response upon palpation pressure and percussion from the tendon hammer (Table 1). There was no palpable nodularity or thickening of the tendo-achilles giving rise to suspicions of secondary hyperalgesia due to aberrant sensitiza-tion of this region. (7,21) Palpation pressure and percussion over the the tarsal tunnel, heel, medial arch, and the tendo-achilles regions all evoked hyperalgesic responses bilaterally, with the right foot being the more severely affected. There were no visible signs of muscle wasting. The patient was referred to a specialists and plain radiographs were order to determine osseous integrity and involvement. Plain radiographs returned unremarkable. Given the nature of the pain experience, and the presentations during the clinical assessment, the working diagnosis was: trauma induced neuropathic pain / complex regional pain syndrome.


Table 1. Pre-treatment basic bilateral neurovascular assessment findings: (++) indicative of normal response. Patient’s peripheral senses were intact, with the only *abnormality seen as a hyperalgesic response to stimulus from a tendon hammer, and Tinel’s response present at the right tendo-achilles.

Intervention and MethodAssessments were conducted prior to each Li-MST session to determine the integrity of the peripheral sensory and vibration perception, as well as the location, quality and presentation of pain symptoms. All NSAID’s and analgesics were ceased prior to treatment commencement and remained discontinued throughout the entire follow-up period of 32 weeks. Pre-treatment VAS and NPDQ-DN4 scores were recorded and continued to be taken prior to each Li-MST session, and were utilized to record post treatment changes through the 32 weeks. The Pain Outcomes Profile (POP) questionnaire was utilized to monitor function, emotional status, and social capacity impacted by the pain experience in the same manner.(8) Three sessions of Li-MST was admin-istered bilaterally at one week intervals propagated by a focused electro-hydraulic generator (MediSpec Ltd. Germantown). The first Li-MST session comprised of 1,400 impulses administered on each foot with a focal zone of 35mm x 90mm over the plantar aspect of the heel. Energy density flux level (EDFL) of 0.11mj / mm² was utilized during the first session. This focal region effec-tively provided a therapeutic dose over the medial tubercle of the calcaneus and the PMLA. Target regions and number of impulses were identical during the second

and third treatments respectively. EDFL was increased to 0.14mj/mm² for the second treatment, and to 0.17mj / mm² for the third treatment. The first Li-MST was conducted on November 26, 2010, and the final treatment was conducted on December 10, 2010. Concurrent intervention included the removal of the fabricated foot orthoses, as it was deemed inappropriate in this instance, and a ShockStop™ insole (Foot Science International, Christchurch, New Zealand) was fitted into footwear at week 3 to provide additional shock attenuation during weight-bearing and ambulation.

ResultA significant difference in pain reduction was observed at the12 and 24 week follow-up periods. The post activity VAS scores dropped from the pre-treatment values of 9.5 and 7 respectively to a 3 at 12 weeks and to a 0.5 at 24 and 32 weeks (Figure 3). Rest pain scores reduced from pre-treat-ment values of 8.5 and 7 respectively to a 1.5 at 12 weeks and 0.5 at 24 weeks, and remained constant at 32 weeks. Dysesthesia which was experienced as a constant burning and episodes of electric shock like sensations was absent bilaterally at weeks 24 and 32 (Figure 3). Patient reported activity increase and the ability to weight-bear and ambulate for longer periods without pain. Patient’s peripheral vibration and sensory perceptions remained intact (Table 2). Both patellar and Achilles tendon stretch reflexes were present at 12 and 24 weeks (Table 2). DN4 questionnaire screened at weeks 12, 24 and 32 all scored a zero respectively. Fear of palpation during physical


assessments and movements were markedly reduced at week 3, and was no longer apparent at 12, 24 and 32 weeks. POP questionnaire showed improvement in emotional and physical status throughout the follow-up period (Figure 4 & 5). Patient was assessed by a specialist on week 24 and by her primary physician on week 32. Both assessors found improvements in both the pain experience and physical activity that corroborated with our own findings.

Table 2. Post treatment basic neurovascular assessment findings: (++) indicative of normal response to assessment. Patient’s peripheral senses remained intact, and the Achilles tendon reflexes were now ascertainable bilaterally

Figure 3. Subjective pain perception after activity using VAS comparing pre-treatment and post Li-MST scores. Subjective changes were recorded prior to each Li-MST session. Pain medications were discontinued, and customized orthoses were removed prior to Li-MST commencement and remained as such throughout the follow-up period. 1st Li-MST was commenced after pre-treatment assessment, 2nd and 3rd Li-MST was conducted on weeks 2 and 3. ShockStop™ insoles were introduced in week 3. Note: pain symptoms and function was improved prior to introduction of ShockStop insoles.


Figure 4. Emotional status from pre-treatment to post intervention at 32 weeks, utilizing the POP questionnaire showed improvements in anxiety and depression levels from baseline. Self esteem recorded marked improvement from week 3 onward. Between weeks 24 and 32, the patient was in employment, which may have further enhanced the overall psychological status.

Figure 5. Physical activity levels, energy, endurance and concentration status from pre-treatment to post intervention at 32 weeks utilizing the POP questionnaire recorded marked improvements in physical activity and energy levels from week 3, and continued to improve up to week 32. Similar improvements were recorded in endurance and concentration levels.

DiscussionIntervention.Medical shockwaves are acoustic pressure waves propagated in this instance by an under-water discharge that rises and travels at supersonic speeds at low amplitudes within the water membrane lasting for approximately 300 nanoseconds. (22,23,25) When shockwaves are gener-ated from a water medium a cavitation phenomenon occurs characterized by negative and positive compressive ossilatory cycles resulting in secondary moments of localized high shear stress in tissue, microstreaming and implosion (Figure 6). (22,23,25) A dose dependant stimulus from this type of sonic energy is seen to actuate a complex spectrum of favorable cellular and molecular effects promoting recovery of compromised tissue. (1,9,17,22,24-28,33,35-37,39-41)Medical shockwaves are seen to trigger a localized cellular and bio-molecular response that improves regional blood circulation, regulate endothelial nitric oxide syntheses (eNOS), collagen syntheses, progenitor cell expression, with a simultaneous down regulation and mediation of cytokines and neurotransmitter such as tumor necrosis factor alpha (TNF-α), glutamate, substance P (SP) and calcitonin gene related peptide (CRGP) among other cellular and bio-molecular effects. (1,9,17,22,24-28,33,35-37,39-41)


Figure 6. The cavitation effect generated by a controlled underwater explosion is the consequence of the forces acting upon the liquid due to rapid pressure changes. This is characterized by a rapid rise time over a short duration period. The resulting cellular sonication modifies the permeability of the cell plasma membrane and the resulting biocellular responses. (Cavitation phenomenon adapted from Journal of “Mineralstoffwechsel” 2004; 11(4), 7-18). Pertinent note: the cavitation effect cannot be produced by a radial type device.

Neuropathic Pain.Pain and pain syndromes may arise as a result of nociceptive, inflammatory, dysfunctional, or neuropathic episodes. (11) Neuropathic pain as described by Costigan and colleagues (11), is a condition that emanates from multiple etiologies where the specific cellular and molecular mechanism for this syndrome has yet to be fully elucidated, and remains a clinical challenge to manage. The abnormal pain response in neuropathic pain conditions are causatively multifacto-rial and often occur without an identifiable stimulus. (7,11,29) Aberrant cytokine activity, periph-eral and central sensitization, ectopic propagation of action potential, physiological neuronal morphology, and laminae sprouting, may all act independently or in concert giving rise to the abnormal pain phenomenon. (7,11,29). The patient in this case report displayed classic symptoms associated with neuropathic pain such as; unexplained ectopic episodes, regional hyperalgesia, tactile allodynia, secondary hyperalgesia and the duration of the pain condition. Hyperalgesia and allodynia when temporary may be considered as a protective response, where the hypershift downward in pain threshold levels is activated due to a nocifensive response to protect the vulner-able site from further damage, causing hypersensitivity to normally innocuous stimulus, and sedentary activities. (7,11,29)

Secondary hyperalgesia was present at the distal mid-stem portion of the tendo-achilles region elicited by both palpation pressure and percussion from the tendon hammer. Secondary hyper-algesia is seen to occur due to the aberrant hyper-excitability of neurons after trauma and in chronic states induce a series of biochemical events that lead up to an altered central processing via mechanosensitive receptor inputs producing a heightened sensitivity or pain response from the surrounding uninjured tissue. (3,7,11,16,21) Projections of neuropathic pain are seen to occur within the territory of the damaged nerve or pathway, and the spatial organization in the primary somatosensory cortex. (3,11,16) The primary lesion in this case-study was considered to be at the medial tubercle of the calcaneus, and the medial aspect of the PMLA. The innervations of these regions arise from the bifurcation of the tibial nerve, and share a common neuronal pathway. (4,3,16) It is plausible to suggest that the aberrant neural hyper-excitability occurring at the primary lesion triggered the secondary hyperalgesic reaction more proximally at the tendo-achilles, as they share a common signaling pathway and close spatial proximity in the primary somatosensory cortex. (3,11,29) In this instance, the resolution of the aberrance at the primary lesion triggered a desensitization at the secondary point. However, given the complexities involved in neuropathic pain phenomenon, it is pertinent to note that the desensitization of the primary lesion may not always automatically desensitize the secondary point of hyperalgesia.


Metabolic syndromeSome form of diabetes related neuropathy may have been present prior to the inciting event as the patient recalled having symptoms of dysesthesia and ectopic episodes occurring at the extremities. It is not uncommon for diabetic patients to develop some form of peripheral neuropathy that affect small and thin peripheral nerve fibers (13,21,34) due to the hyperglycemic induced metabolic aberrance that cause neuronal degeneration, dysfunction and aberrant signal activity. (19,30,34,38) It is uncertain if the inciting trauma potentiated a neuropathic condition that had pre-existed due to long standing diabetes mellitus, or if it was an isolated event. A necessary caution when dealing with peripheral neuropathic pain in diabetic patients is; to be cognizant that in the early stages, heightened pain sensations may later become absent or significantly reduced due to the onset of neuronal insensitivity due to nerve morphology associated with the metabolic disorder. (19,34) It is therefore pertinent to ensure that the absence of pain symptoms in diabetic patients after a lapse of time or treatment is not an onset of neuropathic insensitivity due to disease progression. The resolution of the pain symptoms in this case-study however was considered a positive treatment outcome unrelated to the onset of peripheral insensitivity, as the patient’s vibration and sensory perceptions all remained intact throughout the follow-up period.

Emotional issuesEmotional states are an important factor to consider in patients with chronic disorders including that of pain. In this case study, the combination of the metabolic disorder, persistent pain, disability, and job loss experienced by the patient had severe biopsyhcosocial implications. Another cause of emotional distress for the patient was the sense that family members among others did not believe the severity of her pain experience. Physiological disability in combination with severe emotional strain can have negative impact on an individual’s cognitive functioning and introduce: cognitive decline, neurochemical and neuroendocrine imbalances that can further complicate the issue. (20) The POP questionnaire helped us record and monitor the emotional disposition of the patient throughout the treatment and follow-up periods. It was evident that as the pain symptoms resolved, and activity levels increased, the patient’s emotional and cognitive status improved. The emotional status may have been further enhanced with re-employment.

Neuropathic pain is a persistent condition that is evoked by both spontaneous as well as stimulus-dependant pain. The abnormal peripheral and central sensory amplification is evoked by both low and high intensity stimuli, and may often include ectopic activity. The administration of Li-MST at the periphery in this case-study was successful in modifying the abnormal sensory transmission. Although the biocellular impact of medical shockwaves on human tissue have been previously discussed and partially elucidated, the neural plasticity and cognitive features associated with this treatment in both musculoskeletal and pain medicine has not been previously explored. One of the factor why medical shockwaves tend to yield positive outcomes for chronic injuries and pain syndromes may be due to the fact that the treatment stimulus is ‘a new cognitive experience’. There are several aspects associated with this treatment method that are unique and has never been experience by the individual previously that possibly trigger a keen sense of attention in the individual’s neural circuitry. This ‘keen-attention’ factor could play a pertinent role in the neuro-chemical modulation and physiological effects induced by Li-MST.

The overall outcome of this case report was positive however, some of its shortcomings may be seen in the purely subjective nature of baseline and post intervention outcomes scores. The use of quantitative investigations such as nerve conduction velocity, and sensory perception studies would have helped provide for more quantitative nerve sensory

and conduction observations. The use of shock-stop insoles limits the ability to fully determine the actual impact of Li-MST on the overall treatment outcome. Furthermore results from case reports are insufficient grounds to determine the efficacy of any modality as it is restricted to a single instance. Nevertheless the small number of treatments, its minimally invasive nature, the rapid onset of treatment benefit, and the treatment survival curve, provides the premise for further investigations to be undertaken to determine the role of Li-MST in the treatment of neuropathic


pain syndromes of this nature. The use of Li-MST has not been previously explored in an attempt to treat complex neuropathic pain in diabetic patients. The rationale for its use in this instance was considered after reviewing results of shockwave therapy on complex regional pain syndrome of the knee as reported by Nortarnicol et al.(25), and preliminary investigations by Craig and colleagues (10) utilizing Li-ESWT which successfully restored peripheral sensitivity in an insensate diabetic foot, being the opposite end of the neuropathic spectrum.

ConclusionThe nature of neuropathic pain which is often indocile to conventional treatments warrants the exploration of treatment methods that may provide for a safe and effective solution to treat this often impervious phenomenon. The rationale for the attempt to utilize Li-MST in this instance was based on the mechanism of its action on human tissue that is seen to rehabilitate the cellular, chemical and bio-molecular disruptions caused by trauma. Li-MST may provide an effective non-invasive and potentially disease modifying treatment method that does not introduce intrinsic risk for the treatment of certain types of neuropathic pain conditions. This encourages the devel-opment of a hypothesis to be tested for its potential use in these instances. Further investigation is warranted to determine the efficacy of Li-ESWT for complex and neuropathic pain syndromes.

Acknowledgements

Mr. Bruce C Twaddle – Pre-treatment clinical assessment and post treatment follow-up at week 24.

Dr. Lorna Buhler – Pre-treatment clinical assessment and post treatment follow-up at week 32.

MediSpec Ltd – Providing specialized electrohydraulic soundwave generator.

Note

The ESWT device utilized is not a radial or pneumatic unit, which is unsuitable for treating neuropathic pain conditions.

Reference 1. Amelio E, Manganotti P. Effect of Shock Wave Stimulation on Hypertonic Plantar Flexor Muscle in Patients with Cerebral

Palsy: A Placebo-Controlled Study. J Rehabil Med. 2010 Apr;42(4):339-43. 2. Attal N, Fermanian C, Fermanian J, Lanteri-Minet M, Alchaar H, Bouhassira D. Neuropathic Pain: Are there distinct

subtypes depending on the aetiology or anatomical lesion? Pain. 2008 Aug 31;138(2):343-53. Epub 2008 Mar 4.3. Baron R. “Mechanisms of Disease: neuropathic pain—a clinical perspective”. Nat Clin Pract Neurol. 2006 Feb;2(2):95-106.4. Bilge O, Ozer MA, Govsa F. Neurovascular branching in the tarsal tunnel. Neuroanatomy. 2003 Dec; 2(1):39-41. 5. Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes. 2005 Jun;54(6):1615-25. 6. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking

A, Jafari-Schluep H, Lantéri-Minet M, Laurent B, Mick G, Serrie A, Valade D, Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005 Mar;114(1-2):29-36.

7. Campbell JN, Meyer RA. Mechanisms of Neuropathic Pain. Neuron. 2006 Oct 5;52(1):77-92. 8. Clark ME, Gironda RJ, Young RW. Development and validation of the Pain Outcomes Questionnaire-VA. J Rehabil Res

Dev. 2003 Sep-Oct;40(5):381-95.9. Craig K. Extracorporeal Shockwave Therapy (ESWT), an option for chronic tendinopathy management: a clinical

perspective. Publication of the New Zealand Pain Society 2011 Summer;8-16.10. Craig K, Hing W, Lewis G, Poratt D. An attempt to restore peripheral vibro-sensory perception in an insensate Type 1

diabetic foot. The Journal of Diabetes and Its Complications. Forthcoming 201211. Costiga M, Scholz J, Woolf CJ. Neuropathic Pain: A Maladaptive Response of the Nervous System to Damage. Annu Rev

Neurosci. 2009 32;1-32. 12. Dworkin RH, O’Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JD, Miaskowski C, Nurmikko

TJ, Portenoy RK, Rice AS, Stacey BR, Treede RD, Turk DC,Wallace MS. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007 Dec 5;132(3):237-51.

13. Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, Wilson DM, O’Brien PC, Melton LJ 3rd, Service FJ. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: The Rochester Diabetic Neuropathy Study. Neurology. 1993 Apr;43(4):817-24.

14. Haanpää M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D, Cruccu G, Hansson P, Haythornthwaite JA, Iannetti GD, Jensen TS, Kauppila T, Nurmikko TJ, Rice AS, Rowbotham M,Serra J, Sommer C, Smith BH, Treede RD. NeuPSIG guidelines on neuropathic pain assessments. Pain. 2011 Jan;152(1):14-27. Epub 2010 Sep 19.

15. Hienricher M M. Neuroscience in Medicine. 3rd ed. Oregon: Humana Press; 2008.16. IASP Newsletter. Diagnosis and Classification of Neuropathic Pain. Pain Clinical Updates. 2010;18(7). 17. Koshiyama K, Kodama T, Yano T, Fujikawa S. Structural Change in Lipid Bilayers and Water Penetration Induced by Shock

Waves. Biophys J. 2006 Sep 15;91(6):2198-205. 18. Leinninger GM, Edwards JL, Lipshaw MJ, Feldman EL. Mechanics of Disease: mitochondria as new therapeutic targets in

diabetic neuropathy. Nat Clin Pract Neurol. 2006 Nov;2(11):620-8.


19. Little A.A, Edwards JL, Feldman EL. Diabetic neuropathies. Practical Neurology. 2007;7(2):82–92.20. Llorente MD, Malphurs JE. Diabetes and Depression. In Diabetes and the Brain. New York. Humana Press, 2009.21. Meyer RA, Ringkamp M, Campbell JN, Raja SN. Peripheral mechanisms of cutaneous nociception. In Wall and Melzack’s

Textbook of Pain. London. Elsevier, 2006. 22. Mittermayr R, Hartinger J, Antonic V, Meinl A, Pfeifer S, Stojadinovic A, Schaden W, Redl H. Extracorporeal Shock

Wave Therapy (ESWT) Minimizes Ischemic Tissue Necrosis Irrespective of Application Time and Promotes Tissue Revascularization by Stimulating Angiogenesis. Ann Surg. 2011 May;253(5):1024-32.

23. Moretti B, Iannone F, Notarnicola A, Lapadula G, Moretti L, Patella V, Garofalo R. Extracorporeal shockwaves down-regulate the expression of interleukin-10 and tumor necrosis factor-alpha in osteoarthritic chondrocytes. BMC Musculoskelet Disord. 2008 Jan 31;9:16. Available from: http://www.biomedcentral.com/1471-2474/9/16

24. Moretti B, Notarnicola A, Maggio G, Moretti L, Pascone M, Tafuri S, Patella V. The management of neuropathic ulcers of the foot in diabetes by shock wave therapy. BMC Musculoskelet Disord. 2009 May 27;10:54. Available from: www.biomedcentral.com/1471-2474/10/54/

25. Moretti B, Notarnicola A, Moretti L. Bone healing induced by ESWT: Mini Review. Clin Cases in Mineral and Bone Metabolism 2009;6(2): 155-158.

26. Nataraja, K. N., Udayakumar, M. & Jagadeseh, G.(2004). A novel method of transforming prokaryotic cells using shock waves. Proceedings of the 24th International Symposium of Shock Waves, Vol. 2.

27. Notarnicola A, Moretti L, Tafuri S, Panella A, Filipponi M, Casalino A, Panella M, Moretti B. Shockwave therapy in the management of complex regional pain syndrome in medial femoral condyle of the knee. Ultrasound Med Biol. 2010 Jun;36(6):874-9.

28. Ogden JA, Alvarez RG, Marlow M. Shockwave Therapy for Chronic Proximal Plantar Fasciitis: A Meta-Analysis. Foot Ankle Int. 2002 Apr;23(4):301-8.

29. Sandkuhler J. Models and Mechanisms of Hyperalgesia and Allondynia. Physiological Reviews. 2009; 89(2):707–758.30. Sarantopuulos C. Management of Neuropathic Pain. In Pain Medicine: The Requisites of Anesthesiology. Philadelphia

Mosby Elsevier, 2006. 31. Schaden W, Thiele R, Kölpl C, Pusch M, Nissan A, Attinger CE, Maniscalco-Theberge ME, Peoples GE, Elster EA,

Stojadinovic A. Shock Wave Therapy for Acute and Chronic Soft Tissue Wounds: A Feasibility Study. J Surg Res. 2007 Nov;143(1):1-12.

32. Staud R, Craggs JG, Perlstein WM, Robinson ME, Price DD. . “Brain activity related to temporal summation of C-fiber evoked pain”. Eur J Pain. 2008 November; 12(8): 1078–1089.

33. Taki M, Iwata O, Shiono M, Kimura M, Takagishi K. Extracorporeal Shock Wave Therapy for Resistant Stress Fracture in Athletes. Am J Sports Med. 2007 Jul;35(7):1188-92.

34. Tanenberg RJ, Donofrio, PD. Neuropathic Problems of the Lower Limbs in Diabetic Patients. In Levin and O’Neal’s The Diabetic Foot. 7th ed. Philadelphia: Mosby Elsevier; 2008.

35. Trompetto C, Avanzino L, Bove M, Marinelli L, Molfetta L, Trentini R, Abbruzzese G. External shock waves therapy in dystonia: preliminary results. Eur J Neurol. 2009 Apr;16(4):517-21.

36. Vardi Y, Appel B, Jacob G, Massarwi O, Gruenwald I. Can Low-Intensity Extracorporeal Shockwave Therapy Improve Erectile Function? Eur Urol. 2010 Aug;58(2):243-8

37. Vasyuk YA, Hadzegova AB, Shkolnik EL. Kopeleva MV, Krikunova OV, Iouchtchouk EN, Aronova EM, Ivanova SV. (2010). Initial Clinical Experience With Extracorporeal Shock Wave Therapy in Treatment of Ischemic Heart Failure. Congestive Heart Failure. 2010 Aug;16(5):226-230. Available from: onlinelibrary.wiley.com/doi/10.1111/j.1751-7133.2010.00182.x/pdf

38. Vincent AM, Feldman EL. New Insights into the Mechanisms of Diabetes Neuropathy. Rev Endocr Metab Disord. 2004 Aug;5(3):227-36.

39. Wang FS, Yang KD, Chen RF. Extracorporeal shock wave promotes growth and differentiation of bone-marrow stomal cells towards osteo-progenitors associated with induction of TGF-β1. Journal of Bone and Joint Surgery British Volume. 2002 84(3):457–461.

40. Wang CJ, Liu HC, Fu TH. The effects of extracorporeal shockwave on acute high-energy long bone fractures of the lower extremity. Arch Orthop Trauma Surg. 2007 Feb;127(2):137-42.

41. Wang CJ, Kuo YR, Wu RW, Hsu CS, Wang FS, Yang KD. Extracorporeal Shockwave Treatment for Chronic Diabetic Skin Ulcers. Journal of Surgical Research. 2008 May;152 (1).


IASP MattersMichael Nicholas

The main news this year is probably the decision to move the IASP HQ from Seattle to Washington. The process has since been concluded with the purchase of a floor in a multi-story building a few blocks from the White House. Key motivations for the move included the desire to broaden and secure IASP’s asset base, and to be more closely co-located to other similar international health organizations, like the World Health Organization, to make it easier for IASP to participate at the international table of health policies and debates. Washington is also much easier for Europeans and South Americans to access, but of course, it is further away from our corner of the Pacific. But it doesn’t rain as much as Seattle, I’m told. Still, there was a degree of ambivalence about the move as it also represents a move away from our historical roots in Seattle, as the original HQ founded by Bonica and his colleagues.

In this context it is timely that our new bi-annual newsletter (IASP Insight) has just been launched, and all IASP members will soon receive their copy. The key feature article is on Bonica and the early days in the establishment of IASP. It was kindly written by John Loeser, and it is hoped that the article will provide more recent members of IASP with a useful histor-ical perspective for appreciating the work and significance of IASP. The next edition of IASP Insight is underway, and I would urge all New Zealand members of IASP to consider submit-ting a short article on novel and interesting developments in the field of pain in New Zealand. Details on how to do this are included in the newsletter.

Other news from IASP Head office includes:Council elections – the results of the recent elections have been announced; and, while there are no new members from this side of the Pacific, I would urge you to think of nominating someone for the next elections. There is a strong desire in IASP to ensure the members of Council are representative of the membership from across the world. So, the next election might see an opportunity for the election of one or two from Asia/Pacific region.

Volunteers for IASP Committees – this reminder will be too late for the current call for applications for 3 IASP committees, which close on June 18; but I think it is important to consider putting yourself up for these positions. They afford not only a chance of contributing to the field of pain at the international level, but also an opportunity to develop useful linkages with others who share your interests in pain.

The 14th World Congress on Pain in Milan – preparations are well-advanced for the meeting in August, and it promises all the intellectual stimulation, excitement, and camaraderie that we have experienced at previous IASP meetings. Then there is the food to consider as well. If you can’t make it this time, you will still be able to get copies of the main papers and the refresher courses via the IASP website (either in book or down-loadable forms), so look out for announcements on these. If you are able to come, do feel welcome to visit our team at the University of Sydney booth in the Exhibition Hall (we even have a spare chair or two to allow you to pace your standing time).


NZPS Research Working Group Catherine Swift (NZROT), Arthritis Educator, Arthritis New Zealand Gwyn Lewis, School of Rehabilitation and Occupation Studies, AUT University Erica Gleeson (RN) Clinical Nurse Specialist, Acute Pain Service, Mid Central Health

Helpful tips for using surveys as a data collection method

Late last year the Research Working Group sent members of the New Zealand Pain Society (NZPS) a link to a survey about pain-related research. We received 120 responses, and would like to thank all those who took the time to participate. The aims of the survey were as follows: to ascertain the degree of involvement that members have, or have had, with pain research; barriers and/or facilitators to pain research in New Zealand; and to identify areas of pain that require further research1.

While the response rate to the survey was very heartening, and results can be taken as evidence that there is interest in greater pain-related research in New Zealand, as the majority of respondents were from Auckland the results may not reflect the views of those members living in other regions. The Research Working Group is currently investigating publication options for the survey findings and plan to share this journey with members in future articles. In the meantime, if you are planning to develop a survey, we have set out a few hints or guidelines below.

A survey can be conceptualised as a structured way to collect standardised information from individuals using a question-naire, and can be used once or multiple times (Scheuren, 2012). It is used when information is required from a group of people because existing data is insufficient, or even lacking (Scheuren, 2012). If you are working in other settings and collecting information for non-research purposes, surveys may be helpful if some of the subject matter is sensitive in nature, and privacy or confidentiality is important.

Before developing a survey, it is necessary to consider several questions. What are your specific objectives? What precise information do you want to collect? How do you intend to use the information? Who will the respondents be? What type of survey will you use? How will you analyse the data? Ideally, before administering the final version you should develop at least 1-2 pilot versions of a new survey and test them on a small group of people. Testing will include the overall approach for respondent recruitment, for data collection methods, and for the questionnaire itself. Cognitive testing of the questionnaire is often conducted prior to field testing to develop an understanding of how people interpret and respond to the questions.

When undertaking a survey it is important to obtain a representative sample of your target population. There are a number of strategies to enhance representativeness. All types of surveys can be influenced by self-selection bias, so it is important to obtain as high a response rate as possible by implementing these strategies.

There are three main types of surveys – self-administered surveys (e.g. postal or internet), face to face interviews, and telephone interviews. Each of these methods has its pros and cons, which need to be carefully considered. Firstly, the benefit of a self-administered survey is that it can be undertaken by the respondent without the need for an interviewer (de Vaus, 2004). Postal surveys are still used for self-administered surveys, although many researchers have moved to using the internet. Postal surveys are generally sent to the individual with a return pre-paid envelope. The benefits of this method are that a large geographic area can be sampled, people are familiar with this type of survey, it is cost effective and, as it is generally completed in private, it can obtain responses to sensitive issues (Spiker, 2009). However, postal surveys can have a low response rate, are often returned without responses to some questions; and, if a person does not under-stand the question, may result in inaccurate responses if there is no means to obtain further information. Postal surveys often require literacy skills, generally in English, and it is common for the elderly or people who are illiterate or have difficulty with reading and writing to not participate (de Vaus, 2004).

Internet surveys are becoming increasingly popular as they are easy to use, can be free of charge, and allow for ease of data collection and analysis. A disadvantage is that partici-pants must be technically competent, have access to the internet, and have some means of being informed about the survey, e.g. have an accessible email address (Spiker, 2009). This can introduce a bias in internet surveys, in that the poten-tial participant pool is limited. It is also more difficult to control who has access to, and therefore who responds to, the survey (de Vaus, 2004).

Face-to-face and telephone interviews should be adminis-tered by a trained interviewer. Interviews can offer in-depth questions and responses, and provide a means for immediate clarification of questions; however, they can be time consuming and costly if interviewers have to travel to the participants (Spiker, 2009). Traditionally, face-to-face interviews have the best response rates, and are ideal for asking complex questions and administering lengthy surveys (de Vaus, 2004). There can be problems with the quality of answers as a response bias may be introduced by the interviewer, e.g. a female interviewer may get different responses than a male interviewer (de Vaus, 2004). Telephone interviews, despite sometimes occurring at unreasonable times, can be beneficial as they do not require travel time and have lower interviewer bias rates. However, they may be costly due to use of trained interviewers or the expense of long distance calls.


When developing questions for a survey it is important to be mindful of the types of questions used. Questions can be classified into two main groups; open-ended and closed questions. An open-ended question allows the respondent to formulate their own answer. The advantage of these questions is that they facilitate more in-depth and wide-ranging responses, but it makes analysis of the answers more difficult and time consuming. In closed questions, a set of predeter-mined responses are provided from which the participant chooses an answer. This type of question is much quicker to answer and to analyse, but constrains participants in how they can respond. The leng th of the survey should be considered with your population in mind, as an overly lengthy survey may cause respondent fatigue, which can lead to mistakes or missing responses (Scheuren, 2012). In postal or internet surveys, particular care should be taken with wording of the questions. Double-barrelled or long questions should be avoided. Words should be simple, with no slang, jargon, ambiguous or vague words (de Vaus, 2004).

In the recent survey conducted by the Research Working Group, ‘Survey Monkey’ was used to develop and distribute the document to NZPS members. This approach was chosen after considering what might the most effective means be of making the survey accessible to those living in all regions of the country. Survey Monkey is an internet-based tool which offers a range of survey packages. Each package has different features, and range in price from free to NZ$1200 per year. This was the first time that any of the Group had used Survey Monkey, and overall it was found to be easy to use, with good customer support services. The built-in analysis feature was fantastic, allowing instant information regarding the findings. The only tips that the Group would give prospective users are to be sure to ‘unselect’ the automatic renewal box (found under the tab ‘my account’), if you are paying for your plan by direct debit and only want to run the survey for a set period of time. Secondly, while free, the basic plan only allows you to handle 100 responses, even if you initially collect the data using an upgraded package and then returned to the basic plan, you will still only be able to review 100 responses. So make sure you allow sufficient time to analyse your results before the period of your upgraded plan ends.

Late last year the Research Working Group sent members of the New Zealand Pain Society (NZPS) a link to a survey about pain-related research. We received 120 responses, and would like to thank all those who took the time to participate. The aims of the survey were as follows: to ascer-tain the degree of involvement that members have, or have had, with pain research; barriers and/or facilitators to pain

research in New Zealand; and to identify areas of pain that require further research.

While the response rate to the survey was very heartening, and results can be taken as evidence that there is interest in greater pain-related research in New Zealand, as the majority of respondents were from Auckland the results may not reflect the views of those members living in other regions. The Research Working Group is currently investigating publication options for the survey findings and plan to share this journey with members in future articles. In the meantime, if you are planning to develop a survey, we have set out a few hints or guidelines below.

A survey can be conceptualised as a structured way to collect standardised information from individuals using a question-naire, and can be used once or multiple times (Scheuren, 2012). It is used when information is required from a group of people because existing data is insufficient, or even lacking (Scheuren, 2012). If you are working in other settings and collecting information for non-research purposes, surveys may be helpful if some of the subject matter is sensitive in nature, and privacy or confidentiality is important.

Before developing a survey, it is necessary to consider several questions. What are your specific objectives? What precise information do you want to collect? How do you intend to use the information? Who will the respondents be? What type of survey will you use? How will you analyse the data? Ideally, before administering the final version you should develop at least 1-2 pilot versions of a new survey and test them on a small group of people. Testing will include the overall approach for respondent recruitment, for data collection methods, and for the questionnaire itself. Cognitive testing of the questionnaire is often conducted prior to field testing to develop an understanding of how people interpret and respond to the questions.

When undertaking a survey it is important to obtain a representative sample of your target population. There are a number of strategies to enhance representativeness. All types of surveys can be influenced by self-selection bias, so it is important to obtain as high a response rate as possible by implementing these strategies.

There are three main types of surveys – self-administered surveys (e.g. postal or internet), face to face interviews, and telephone interviews. Each of these methods has its pros and cons, which need to be carefully considered. Firstly, the benefit of a self-administered survey is that it can be undertaken by the respondent without the need for an interviewer (de Vaus, 2004). Postal surveys are still used for self-administered


surveys, although many researchers have moved to using the internet. Postal surveys are generally sent to the individual with a return pre-paid envelope. The benefits of this method are that a large geographic area can be sampled, people are familiar with this type of survey, it is cost effective and, as it is generally completed in private, it can obtain responses to sensitive issues (Spiker, 2009). However, postal surveys can have a low response rate, are often returned without responses to some questions; and, if a person does not under-stand the question, may result in inaccurate responses if there is no means to obtain further information. Postal surveys often require literacy skills, generally in English, and it is common for the elderly or people who are illiterate or have difficulty with reading and writing to not participate (de Vaus, 2004).

Internet surveys are becoming increasingly popular as they are easy to use, can be free of charge, and allow for ease of data collection and analysis. A disadvantage is that partici-pants must be technically competent, have access to the internet, and have some means of being informed about the survey, e.g. have an accessible email address (Spiker, 2009). This can introduce a bias in internet surveys, in that the poten-tial participant pool is limited. It is also more difficult to control who has access to, and therefore who responds to, the survey (de Vaus, 2004).

Face-to-face and telephone interviews should be adminis-tered by a trained interviewer. Interviews can offer in-depth questions and responses, and provide a means for immediate clarification of questions; however, they can be time consuming and costly if interviewers have to travel to the participants (Spiker, 2009). Traditionally, face-to-face interviews have the best response rates, and are ideal for asking complex questions and administering lengthy surveys (de Vaus, 2004). There can be problems with the quality of answers as a response bias may be introduced by the interviewer, e.g. a female interviewer may get different responses than a male interviewer (de Vaus, 2004). Telephone interviews, despite sometimes occurring at unreasonable times, can be beneficial as they do not require travel time and have lower interviewer bias rates. However, they may be costly due to use of trained interviewers or the expense of long distance calls.

When developing questions for a survey it is important to be mindful of the types of questions used. Questions can be classified into two main groups; open-ended and closed questions. An open-ended question allows the respondent to formulate their own answer. The advantage of these questions is that they facilitate more in-depth and wide-ranging responses, but it makes analysis of the answers more difficult and time consuming. In closed questions, a set of predeter-

mined responses are provided from which the participant chooses an answer. This type of question is much quicker to answer and to analyse, but constrains participants in how they can respond. The leng th of the survey should be considered with your population in mind, as an overly lengthy survey may cause respondent fatigue, which can lead to mistakes or missing responses (Scheuren, 2012). In postal or internet surveys, particular care should be taken with wording of the questions. Double-barrelled or long questions should be avoided. Words should be simple, with no slang, jargon, ambiguous or vague words (de Vaus, 2004).

In the recent survey conducted by the Research Working Group, ‘Survey Monkey’ was used to develop and distribute the document to NZPS members. This approach was chosen after considering what might the most effective means be of making the survey accessible to those living in all regions of the country. Survey Monkey is an internet-based tool which offers a range of survey packages. Each package has different features, and range in price from free to NZ$1200 per year. This was the first time that any of the Group had used Survey Monkey, and overall it was found to be easy to use, with good customer support services. The built-in analysis feature was fantastic, allowing instant information regarding the findings. The only tips that the Group would give prospective users are to be sure to ‘unselect’ the automatic renewal box (found under the tab ‘my account’), if you are paying for your plan by direct debit and only want to run the survey for a set period of time. Secondly, while free, the basic plan only allows you to handle 100 responses, even if you initially collect the data using an upgraded package and then returned to the basic plan, you will still only be able to review 100 responses. So make sure you allow sufficient time to analyse your results before the period of your upgraded plan ends.1. Prior to circulation it had been determined via a review of the national

ethics guidelines that ethical approval was not required to undertake this survey.

References • de Vaus, D. (2004). Structured questionnaires and interviews. In V.

Minichiello, G. Sullivan, K. Greenwood, & R. Axford (Eds.), Research methods for nursing and health science (2nd ed., pp. 347-392). Australia: Pearson Education Australia.

• Scheuren, F. (2012). What is a survey. Retrieved 28th May, 2012 from www.whatisasurvey.info.

• Spiker, S. (2009) Pros and Cons of Survey Methods: Data Collection via Mail, In-Person, Phone, Internet, & Focus Group | Suite101.com http://sarah-spiker.suite101.com/pros-and-cons-of-survey-methods-a149499#ixzz1vT7bwEex


Education Working Group ReportIn 2011 the New Zealand Pain Society Education Working Group conducted a review of international curriculum guidelines and recommendations for the education of pain and pain management. This included the education of medical practitioners and allied health professionals. We found that guidelines were remarkably easy to source for a range of disciplines, with the International Association for the Study of Pain (IASP) providing particularly clear information for Medical Schools, dentistry, nursing, pharmacy, psychology, physical therapy, and occupational therapy. While the information from international sources was useful, we did need to be mindful that the scope of practice for various professions is often different overseas from New Zealand, particularly in the allied health area; and that the various disciplines are frequently taught at a mixture of undergraduate and postgraduate levels.

The overwhelming theme across the guidelines reviewed was the recommendation for multidisciplinary education. Currently, there remains an emphasis on the medical model for pain education across most health disciplines. For a broader understanding of the pain system, and an apprecia-tion of the complexity of diagnosing and managing many chronic pain conditions, a biopsychosocial approach that addresses the multidimensional nature of pain is strongly recommended. This should encompass physical, psycho-logical, social, and behavioural aspects and how they influence the pain experience. For example, recommended pain educators for undergraduate medical students include anaesthetists, palliative care physicians, nurse educators, emergency physicians, surgeons, pharmacists, physiothera-pists, and psychologists. In an ideal world, we suggest that not only would the educators involved in such curricula represent the multiple disciplines involved in pain and pain manage-ment, but the students themselves would represent multiple disciplines. Whilst challenging to implement, this approach would clearly highlight the multidimensional nature of pain and pain management, and provide an longterm goal for our Education Working Group to work towards.

A detailed recommendation for pain education for medical doctors in Australia was particularly close to home.1 These guidelines were developed by the Faculty of Pain Medicine (Australian and New Zealand College of Anaesthetists [ANZCA]) in response to a report2 that final year medical students and recent medical graduates thought that their level of pain and pain management knowledge was insuffi-cient (a similar survey across New Zealand health profes-sionals is planned by our Working Group for 2013). The report suggested that pain education for postgraduate medical students was unstructured and rather lacking in many

Australian medical schools. In our informal review of education in New Zealand medical schools, we found no evidence that pain education was any different on this side of the Tasman. Of interest, as well as providing a detailed recommendation for curriculum content, the report also provided example tests and assessments that could be used to evaluate student knowledge. Our working group would be rather intrigued how experienced medical and allied health practitioners would fare in such tests, as well as their more recently graduated colleagues.

The Education Working Group has put forward some of our findings and recommendations to selected tertiary educators and institutions in the hope that the standard of pain and pain management education can be raised in this country. So far, there have been a couple of doors opening, and we hope that future reports in this column may be able to share some positive outcomes from our work.

Trinca J., Shipton E. Desired competencies in Post Graduate Years 1 and 2. Retrieved from www.fpm.anzca.edu.au.

Trinca, J. (1998) Knowledge of Pain Mechanisms and Management in Recent Medical Graduates (comparison with other Health-Care Students and Graduates). Master’s thesis, University of Sydney.


‘NOI 2012’ was the second Neurodynamics & the Neuromatrix Conference organised by the Neuro Orthopaedic Institute of Australia, fronted by David Butler of “Explain Pain” fame. NOI is a private company based out of Adelaide doing great things in neuroscience and pain management education worldwide, through their seminars and publications. Billed as more a festival than a conference, (the “Woodstock of Neuroscience”), it certainly delivered all the buzz and love of this namesake, but thankfully minus the 1969 fashion!

In typical NOI, biopsychosocial style, the packed programme covered a wide range of topics, canvassing all that is “juicy” or new in neuroscience: plasticity, mirror neurones, pain and stress literacy, neuroscience-backed psychology, neuroimmu-nology, neurodynamics and movement sciences, all delivered by a large range of high quality speakers. Right from the first talk on Day 1, through to the last on Day 3, the jam packed programme repeatedly challenged and inspired me. To steal the words of Dr Fiona Wood, who gave the opening address, right from the first talk it was “blinkers off, game on”.

The overarching aim of the conference was to bridge the gap between advances in neuroscience knowledge and clinical practice. With over 20 different professions represented among the delegates, the cross pollination and sharing of ideas between professions was another strong thread throughout the conference. This diversity was also evident in the variety of backgrounds of the invited speakers, who ranged all the way from a Plastic Surgeon, to a Professor of Theology.

Louise SheppardPhysiotherapist, Christchurch

NOI Neurodynamics and the Neuromatrix Conference:Adelaide, April 2012

In late April this year I was lucky enough to attend the ‘NOI Neurodynamics and the Neuromatrix Conference’ in Adelaide.

One of my favourite talks was from Professor Charles Spence, who is the science behind the hit TV show “Heston’s Feast”. Professor Spence, who is head of Experimental Psychology at the University of Oxford, gave a keynote address on the emerging field of “Neurogastronomy” – where neuroscience meets molecular gastronomy. He proved just how easily our senses, including taste, can be fooled. For example, 7UP fielded a raft of disgruntled calls from customers complaining the drink was now too “lemony” after doing nothing more than changing the shade of green of their can (and not changing the recipe at all!)

Mick Thacker, of the Pain, Science and Society department at Kings College in London, gave an entertaining tour of the “sticky-stars” of our neural universe (microglia and astrocytes) and outlined new directions in the area of neuroimmunology and pain.

Dr Sandy McFarlane, Professor of Military and Veterans Health at the University of Adelaide, gave a thought-provoking talk about the impact of traumatic stress and physical health, and the overlap between mental health disorders and pain states, which share a common neurobiology. As I listened to his talk, I was stuck by the implications of this area of research on the future of young Cantabrians, as it seems that trauma and stress tend to have progressive accumulation with the passage of time.

Lorimer Moseley, who is not only a mover and shaker in the world of neuroscience, but an entertaining and engaging


speaker, gave a whirlwind talk on the state of research on the cortical body matrix. Recent work in this area, such as that people with low back pain demonstrate a type of neglect of not only their painful side but the space around it, and that there seems to exist a mind line reference on autonomic control, has huge potential implications for clinical practice, and I am still trying to wrap my head around what these things could potentially mean.

Steve Williams, also from Kings College, this time from the Centre for Neuroimaging Sciences, spoke about the new gadgets and advances in neuroimaging including super quiet functional MRI scanners that allow scans of sleeping infants in their first year of life. Steve also extrapolated to some of the things fMRI could potentially be used for (but are not), including lie detection and facial recognition to thwart terrorist attacks, which gave a sense of the power of this “big boy’s toy”.

New Zealand was well represented by our own Dr Mike Butler and Ben Darlow, who did a great job of flying the kiwi flag; and I was proud to sit in the audience as both delivered eloquent and interesting talks.

One of the best things about the conference was the lunch time activities on offer. Despite being allowed a generous 90-minutes, the lunchtime each day disappeared quickly among the activities on offer, ranging from a tattooing demonstration to salsa dancing. Between eating and social-ising, I also watched my median nerve slide, my index finger

shrink, a rubber hand replace my own, and had my taste buds fooled by a glass. There were also four 90-min workshop sessions over the course of the conference, with 9 different choices for each session: one of the most difficult aspects of the conference was choosing which to attend. The festival dinner was also predictably a highlight of the conference. Showcasing South Australian wines and produce, the dinner entertainment included acrobats, Samba dancers, and appar-ently the longest conga line the Adelaide Convention Centre had ever seen!

I came away from the three day conference with a two page list of ideas, inspiration and things to follow up, which I imagine I may still be working through by the time NOI 2014 rolls around. I would like to thank the NZPS for assisting me to attend such a great conference. More information on NOI and what they do at www.noigroup.com or the conference itself at www.noi2012.com.


PresidentDr Ross DrakePaediatric Palliative Care and Complex Complex Pain ServicesSupport BuildingLevel 10Auckland City HospitalPrivate BagAucklandp: (09) 307 4949 ext: 22741e: [email protected]

TreasurerMs Jenny SandomPain Relief ServicesC/o Dept of AnaesthesiaDunedin HospitalPO Box 1921Dunedin Phone: (03) 474 0999 ext: 8648e: [email protected]

Membership SecretaryMrs Joni Scandrett-Hollows16 Swinford CrescentJohnsonvilleWellington 6037p: (04) 970 2876e: [email protected]

Chair – Education Working GroupDr Gwyn LewisHealth and Rehabilitation Research InstituteAUT UniversityPrivate Bag 92006Auckland 1142New Zealandp: (09) 921 9999 ext: 7621f: (09) 921 9620e: [email protected]

Chair – Education Working GroupCatherine Swift705a Grey Street Hamilton 3206p: 021 906 464 (07) 843 4701e: [email protected]

President-ElectDr Brigitte GertoberensThe Auckland Regional Pain ServiceGreenlane Clinical CentrePrivate Bag 92 189Auckland Mail CentreAuckland 1142p: (09) 3074949 ext: 27896e: [email protected]

CouncillorDr Gwyn LewisHealth and Rehabilitation Research InstituteAUT UniversityPrivate Bag 92006Auckland 1142New Zealandp: (09) 921 9999 ext: 7621f: (09) 921 9620e: [email protected]

CouncillorDr John Speirsc/- Anaesthetic DepartmentWellington HospitalPrivate Bag 7092Wellingtonp: (04) 385 5920e: [email protected]

CouncillorCatherine Swift705a Grey Street Hamilton 3206p: 021 906 464 (07) 843 4701e: [email protected]

CouncillorMs Bronwyn ThompsonDepartment of Orthopaedic Surgery and Musculoskeletal MedicineUniversity of OtagoChristchurchPO Box 4345Christchurch 8140p: (03) 383 6831 ext: 99926f: (03) 364 0909e: [email protected]

SecretaryDr Natalia ValentinoService Development ManagerArthritis NZ Northern Regional OfficeUnit B383 Khyber Pass RoadNewmarketAuckland 1023p: (09) 5238907m: 0272410979e: [email protected]

Ngau Mamae Editor-in-chiefDr John AlchinPain Management CentreBurwood HospitalPrivate Bag 4708Christchurch 8140p: (03) 383 6831f: (03) 383 6832e: [email protected]

Ngau Mamae Deputy EditorAndrew FairbairnPain Management CentreBurwood HospitalPrivate Bag 4708Christchurch 8140p: (03) 383 6831f: (03) 383 6832e: [email protected]

NZPS Council Members 2012 – 2013

New Zealand Pain Society Inc.

Registration Form for New MembershipDate

Name

Mailing Address

Alternative Address(not for publication)

Telephone (work)

Fax

Email

Present Clinical Title of Affiliation

Discipline

Institutions in which you work in the field of pain

Proportion of working week in the field of pain

Classification of practice setting □ Modality-oriented Clinic □ Multidisciplinary Pain Centre

□ Multidisciplinary Pain Clinic □ Solo

□ Pain Clinic □ Other

Patient Group □ Inpatient □ Private

□ Outpatient □ Public/Private

□ Public

Particular Interests

Other Affiliations (list other major national or international scientific and health professional organisations to which you belong)

Course of Study (if you are a student)

Are you a member of the IASP □ no □ please send me membership details for IASP

□ yes

We intend distributing regularly to NZPS members only, an updated membership list. If there is any portion of the information on this page that you would prefer to be kept out of the membership list, please place an asterisk * beside it.

Turn page for subscription costs✁

Subscriptions □ If receipt required please tick box

□ $50 Annual subscriptions ( year starts 1st April )

□ $25 If application received 1st October – early March

□ $20 Full time student per year

□ General fund □ Pediatric fund(NZPS has been granted charitable status for donations over $5)

Make cheques payable to New Zealand Pain Society Inc.

Please send payment and application form to

Mrs Joni Hollows16 Swinford CrescentJohnsonvilleWellington 6037

Email [email protected]

Phone/Fax (04) 9702 876

Note • Please inform the Treasurer of any change in address. • Please inform the Treasurer if temporary residence overseas is planned

and membership is still desired. • Temporary suspension of subscription dues and newsletters is provided

for in the Constitution. Resignation from the Society will be assumed if subscriptions remain unpaid for two consecutive years.

IASP Classification of Practice Setting

Modality-oriented Clinic • Provides specific type of treatment, eg. nerve blocks, TENS acupuncture, etc • May have one or more health care disciplines. • Does not provide an integrated, comprehensive approach.

Pain Clinic • Focuses on the diagnosis and management of patients with chronic pain, or may specialise in specific

• diagonses of pain related to a specific region of the body. • Does not provide comprehensive assessment or treatment. • A single physician functioning within a complex healthcare institution

which offers appropriate consultative and therapeutic services would qualify, but not an isolated solo practitioner.

Multidisciplinary Pain Clinic • Specialises in the multidisciplinary diagnosis and management of patients with chronic pain.

• Staffed by physicians of different specialities and other healthcare providers. • May have facilities that are inpatient, outpatient or both. • Differs from a Multidisciplinary Pain Centre only because it does not

include research and teaching.

Multidisciplinary Pain Centre • An organisation of healthcare professionals and basic scientists that includes research, teaching, and patient care in acute and chronic pain.

• Typically a component of a medical school or a teaching hospital. • Clinical programmes supervised by an appropriately trained and

licensed Director. • Staffed by a minimum of physcian, clinical psychologist or psychiatrist,

occupational therapist, physiotherapist, and registered nurse. • Services provided must be integrated and based upon interdisciplinary assess-

ment and management. • Offers both inpatient and outpatient programmes.

contents society pub 2012...she was born in te hapua, educated at queen victoria college and...

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