This Might Hurt is a documentary describing the work of Dr Howard Schubiner. Viewers follow the moving stories of a group of chronic pain patients for whom conventional medicine had little to offer other than opiates and other drugs or potentially harmful unnecessary surgery. Most of them found significant relief using a structured program examining the underlying emotions contributing to their physical symptoms.
This approach has been used at our office for many years.
Despite robust evidence for myriad ailments and sound
mechanistic data, hypnosis is underused by internists. Using
hypnosis fulfills our pledge to abide by evidence-based
treatments that alleviate suffering with the least collateral
harm, but there is a discrepancy between its benefits and
physicians who offer the treatment. Although hypnosis may
appear in the medical curricula at academic powerhouses
like Baylor, Harvard, Columbia, and Stanford, hypnosis
training is rare even at these institutions. Here is why a
modern resurrection of the oldest Western form of psychotherapy
should inspire internists to get trained and offer
medical hypnosis broadly.
Hypnosis, and its myths and misconceptions, have
evolved since the 18th century when Franz Mesmer inadvertently
led hypnosis into obscurity with his theory about
manipulating a force called “animal magnetism.” These
claims were dispelled by the French Royal Academy of Sciences,
and it took nearly 100 years for Scottish physician
James Braid to first describe a mental and suggestive theory
of hypnosis as a waking physiologic state. The 2014 definition
from the American Psychological Association’s Division
30 describes hypnosis as “a state of consciousness
involving focused attention and reduced peripheral awareness
characterized by an enhanced capacity for response to
suggestion.” Long-standing empirical evidence demonstrates
that hypnosis impacts perception, symptoms, and
habits, which have recently been explained by advanced
diagnostic modalities like functional magnetic resonance
imaging (fMRI). Changes during hypnosis include reduced
activity in the dorsal portion of the anterior cingulate cortex
(a key component of the salience network) and connectivity
between the prefrontal cortex and the insula (a pathway
for mind-body control).1 Augmented by data on neurotransmitter
metabolism and genetics, the neurophysiologic
basis of hypnosis is no longer mysterious. Though our
understanding of the mechanism of action of hypnosis is
more robust than that of even acetaminophen, this has not
sufficed to enhance its use.
Skeptics describe hypnosis in 1 of 3 ways: dangerous
mind control, an ineffective farce, or placebo. It is often
viewed as a loss of control and, therefore, dangerous, when
in fact it is a powerful means of teaching patients how to
control mind and body. The ability to enter into hypnosis,
termed hypnotizability, is a stable trait possessed by most
people, which can be entered into or terminated by the
patient. It is not effective in the presence of conditions such
as stroke or schizophrenia or impaired focused attention or
language processing. Hypnosis is more powerful than placebo
(though patient expectancy is a moderating factor),
and placebo effect is blocked by administration of naloxone,
while the hypnotic analgesia is not.2
Reviews on hypnosis for internal medicine topics are
impressive,3 with demonstrated efficacy for migraine headache,
4 irritable bowel syndrome,5 and anxiety.6 Hypnosis
improves procedural pain and emotional distress and
reduces medication consumption up to 40%7--in short, if
hypnosis were a drug, it would be standard of care. Internists
should prescribe hypnosis particularly when it outperforms
the current standard of care by safety and efficacy, as
in the case of opioids and sedatives.
Patients have a strong appetite for taking charge of their
symptoms; online hypnosis videos for anxiety and insomnia
boast 15-19 million views, and medical hypnosis is quite
acceptable by patients.8 But patients cannot be expected to
differentiate between legitimate and manipulative sources
of hypnosis online any more than if they bought pills off
the street. This treatment modality falls under the purview
of medicine, and our duty is to provide safe access. To do
this, we must improve the supply.
Formal training for medical providers is offered through
national societies, such as the American Society of Clinical
Hypnosis (ASCH) and Society for Clinical and Experimental
Hypnosis (SCEH). Trainings span 4 days and include
ethics and informed consent in addition to practical skills.
Hospital credentialing for the privilege of hypnosis may be
required: If none exists, designing one to include formal
training and mentorship requirement is advised. For
ARTICLE IN PRESS
Conflicts of Interest: None.
Authorship: Both authors had access to the data and a role in writing
Requests for reprints should be addressed to Jessie Kittle, MD, 300
Pasteur Dr MC 5210, Stanford, CA, 94305.
E-mail address: firstname.lastname@example.org
0002-9343/© 2020 Elsevier Inc. All rights reserved.
Fibromyalgia is a common long-term condition, affecting 2-4% of the population, more commonly women than men, that causes pain all over the body along with many other symptoms. People with fibromyalgia often have:
Books and articles often say that the causes of fibromyalgia are unknown. It may be that it is the final destination arrived at from a variety of different starting points. For some people it occurs after an illness such as influenza; for others after an accident or other traumatic event. For many it develops gradually after an overwhelming incident or as the culmination of years of accumulated stressful events, often dating back to childhood. Numerous studies have found that between 50 and 63% of patients with fibromyalgia also meet the criteria for post-traumatic stress disorder, frequently reporting adverse childhood events or subsequent physical or emotional trauma. Adverse childhood events (such as the loss of a parent, abusive or chaotic households, early hospitalizations, accidents, neglect etc), and later traumas all can prime the nervous system's fight/flight/freeze response, giving rise to a sense of being unsafe in the world, and cause the body to respond with physical symptoms. Chronically elevated stress hormones change the way our glucose metabolism and digestive function work, cause increased muscular tone (tight muscles), and affect our immune system function.
There is a complex inter-relationship between our nervous systems, our hormones, immune systems, gastrointestinal system, and our muscular function, including how the energy powerhouses (mitochondria) in our cells function. In other words, although it is a very real physical condition, the pain is being produced in the nervous system in response to (usually prolonged and cumulative) internal (such as the demands or expectations we place on ourselves) and external sources of stress. It can also be triggered by sleep deprivation in some people.
For this reason, it is possible to turn the pain down or even off, by means of techniques that address past trauma, anxiety, stress, beliefs and expectations, as well as by optimizing nutrition, sleep and general well-being through regular exercise (while avoiding extreme of activity). Coming to an understanding of the condition reduces fear, which in turn can substantially reduce pain intensity.
Fibromyalgia can be best thought of as a central nervous system condition in which the brain and spinal cord are sensitized and therefore respond to sensations which are perceived as much more painful than the same sensation would be experienced by someone without fibromyalgia. It is sometimes referred to as a Central Pain Amplification Disorder. Similarly, people with irritable bowel syndrome will perceive the same degree of gaseous intestinal distension as being much more painful than someone without IBS would do. It is as though the pain ‘thermostat’ or dial has been turned up to a very high level.
Unlike rheumatoid arthritis or lupus, fibromyalgia is not an autoimmune or inflammatory condition. It can co-exist with arthritis but it is not primarily a joint condition. It does not lead to any ilife-threatening disease.
Fibromyalgia may run in families to some extent but whether this is genetic or due to a common environment (similar stresses) or a learned response to adverse circumstances is not clear. A small subset of people with symptoms suggestive of fibromyalgia have been found on skin biopsy to have an abnormality of small nerve fibres. Genetics alone cannot explain fibromyalgia. Symptoms tend to be worse with stress, over-work, excessive exercise, or sleep deprivation.
1. symptoms as mentioned above, present for more than 3 months with no other explanation
2. pressure at certain common soft tissue points on physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain.
There is no specific blood test or X-ray that can diagnose fibromyalgia. Commonly tests will be ordered to exclude other conditions, for example, sleep apnea, an underactive thyroid, or polymyalgia rheumatica, anemia, iron-deficiency, rheumatoid arthritis or lupus.
While there is no one specific cure for fibromyalgia, approaching it from a number of different angles – certain medications, carefully structured aerobic exercise within one’s capabilities, and mind-body approaches such as relaxation, stress-reduction, Cognitive Behavioural Therapy, mindfulness, Tai Chi, and clinical hypnosis or guided imagery, can be helpful. Ensuring adequate sleep is essential. Some people have co-existent anxiety, depression, PTSD, panic disorder, all of which can also be treated. Proper nutrition is also important. Anecdotally, some patients report a correlation between pain intensity and diet, such as refined carbohydrates, gluten, nightshades, or meat. This may be an individual response.
A number of medications are often tried to reduce symptoms. Most of these are “off-label”.
Low doses of an antidepressant called amitriptyline (Elavil) or related medications (such as nortriptyline or trazodone) can often be very helpful for pain, sleep, and to reduce migraines.
A muscle relaxant such as cyclobenzaprine (Flexeril) can be helpful. This is structurally similar to tricyclic antidepressants (TCAs) such as amitriptyline.
A newer SNRI medication, duloxetine (Cymbalta) can sometimes help.
Additional medications include pregabalin (Lyrica) and gabapentin (Neurontin) can be used.
Another off-label medication is low dose naltrexone.
Opioid narcotic medications are best avoided as they have significant side-effects, are largely ineffective, addictive and can lead to a conditions known as opiate-induced hyperalgesia, a parodoxical increase in pain the more opiates one cosumes. Of the opiates Tramadol may be better than the others but shares all the same risks as other opiates and interacts with other medications.
Acetaminophen and anti-inflammatories (such as ibuprofen) are generally not effective for fibromyalgia but may help other co-existing pain. Sleeping tablets such as Zopiclone and benzodiazepines are not recommended.
One small study published in December 2018 suggested that some patients with fibromyalgia may respond to treatment with a diabetes drug called metformin if their average sugar level (HBA1C) was in the high normal or elevated range.
Gaining an understanding of fibromyalgia, engaging in self-care, ensuring good sleep, reducing stress, modifying behaviour, counselling, dietary modifications and supplements, and a judicious exercise regimen can all be helpful.
In my own practice a combination of tender point injections, counselling, relaxation techniques, clinical hypnosis, medication and nutritional advice, and patient-education (which may include recommended reading and journalling) can lead to a significant reduction in symptoms, periods of remission, or even resolution.
Experts in managing stress-induced illness and pain have produced a new book titled Psychophysiologic Disorders. It is available from Amazon in paperback and Kindle formats and free to subscribers of Kindle Unlimited. It is a comprehensive, in-depth, and up to date approach, reflecting the latest in neuroscience.
It describes a host of different stress-induced conditions and how they can be managed.
Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment Paperback – Nov. 13 2019 by David Clarke MD, Howard Schubiner MD, et al.
Physicians and allied mental health professionals have created an App that you can use gradually over time to help both educate yourself and manage the symptoms you have, once your condition has been properly evaluated medically. The Curable App can be downloaded from the appropriate App Store for your device and requires an annual subscription.
This therapy for neurogenic pain is sometimes referred to as neural prolotherapy, perineural injection therapy (PIT) or the Lyftogt (pronounced "Lift-off") technique after its developer, Dr John Lyftogt of Christchurch, New Zealand. John is a family physician, runner, and sports medicine doctor who for many years used the trigger point injection methods described so well by Drs Janet Travell and David Simons. He later was trained in traditional prolotherapy. Being an athlete he suffered from chronic achilles tendinopathy and decided to treat himself with prolotherapy by injecting his achilles tendons with concentrated dextrose and local anesthetic. He found this quite painful but found that subcutaneous (just under the skin) injections around the achilles tendons were not painful but in fact eradicated the pain and caused gradual healing. As traditional prolotherapy uses concentrated dextrose (20% or more) he published a number of studies using concentrations of 20-40% dextrose. By 2010 he discovered that isotonic dextrose 5% (D5W) could achieve the same results. After studying the literature on neurogenic pain and the anatomy of skin nerves he discovered that a large number of musculoskeletal pain conditions could be successfully treated by injecting 5% dextrose under the skin next to these sensory skin nerves. These findings were reproduced using 5% mannitol (a sugar-alcohol) in the same manner. John has recently retired from clinical practice in order to devote his time to teaching this method in centres around the world.
Having developed this from a background in prolotherapy he named the new technique "neural prolotherapy" and continues to use that term even though it is somewhat of a misnomer ( the 'prolo' part of the term refers to 'proliferation' of cells which is part of the healing process but requires higher concentrations of dextrose than the 5% he uses now). Others have called this technique "perineural subcutaneous injections" as that is a more accurate descriptor of the process involved. It is postulated that dextrose switches off the (TRPV1) nerve receptors involved in neurogenic inflammation but not the nerve endings which transmit other sensation (i.e. one cannot use dextrose to anesthetize the skin for procedures such as stitches).
The technique involves identifying tender skin nerves and, using a very fine, short (half inch 27 guage or even 32 gauge in sensitive areas like the face) hypodermic needle to inject small amounts (1/2-1ml) of 5% dextrose or 5% mannitol next to the tender nerves. At sites where nerves exit through small holes in the fascia or traverse fibrous tunnels over bones (e.g. the cluneal nerve in the lower back) larger volumes (2-6ml) are injected.
Hundreds of physicians around the world have accumulated considerable clinical empirical experience with this technique and found it very effective.
Some examples in our experience:
1. a lady presented with intense pain in her arm after taking up pickle ball. She was tender over the outside of her elbow (the lateral epicondyle) but also over the skin nerves (branches of the radial and musculocutaneous nerves: lateral and posterior antebrachial and nerve to anconeus) . Each tender point was injected with D5W and she was pain free. She needed 3 treatments over the next two weeks to make this permanent. That is much quicker permanent recovery than with steroids or physiotherapy.
2. another presented with tennis elbow after already having physiotherapy with limited results and only required one D5W treatment.
3. an elderly lady fell on the ice and fractured her hip and several ribs. She bled into her chest cavity and required an incision between her ribs to insert a chest tube drain and also had her hip pinned surgically. With excellent orthopaedic surgical care she made a full recovery but presented several months later with intense pain in and around both scars - chest and hip. Injecting D5W into the tender areas around each scar relieved her pain instantly and avoiding the risks of narcotic pain medications. As expected, some of her pain recurred a few days later but was less intense. In all, she required 3 treatments to obtain a permanent relief for something which could have become a chronic condition. Scar neuromas (tender injured skin nerves in scar tissue) often respond well to this treatment.
4. a mountain biker with a ten-year history of low-back pain was tender over the cluneal and neighbouring cutaneous nerves over the iliac crest of his pelvis. Only two treatments were needed.
5. a patient presented with intense burning pain involving the entire lower limb which came on after an over-vigorous massage for a calf injury. This illustrates how neurogenic pain can spread from the original site of injury. She was tender at multiple sites in her thigh, around the knee and in the lower leg (corresponding to the sensory distributions of the lateral and anterior femoral cutaneous, common peroneal, sural and saphenous nerves). Meticulously each tender point was injected with D5W and much to her surprise she climbed off the examination table pain-free. It is our aim to have the patient pain-free by the end of the visit. If this can be achieved and the pain-relief lasts at least 4 hours after the first treatment the likelihood is good that incremental progressive improvement will be achieved over a few visits.
6. one had severe pain for decades in her back, chest wall, neck and shoulders after a series of accidents. After each treatment she was pain-free for a few days and progressed enough to be able to resume activities such as sports and enjoying games with her son who had never previously seen her able to do so.
Usually the pain-relief lasts 4 hours to 4 days initially, occasionally up to 2 weeks. Very occasionally it is permanent after one visit. This is not a realistic expectation. Most people need 6-8 visits to be substantially or completely better. Some need a top-up a few times per year. Some need more. In some cases one reaches a plateau of about 50% or more reduction in pain overall without permanent complete relief.
These are success stories. Some people do not tolerate needles. We have patients who do not find this method beneficial and so we look for other alternatives. One can usually tell quite quickly whether or not the method is going to be helpful. We have others who need more treatments (8 or more) or who need a combination of neural and traditional prolotherapy or deeper trigger point injections. Some people may do better with physiotherapy.
David is a fan of books and no doubt will be sharing some good reads here.