HOTAL TRADITIONAL ORIENTAL MEDICINE LETTERS, VOLUME 2, NUMBER 1

2015

Findings on Chronic Pain Management
Nobuyuki Otsuka
Hotal Ancient Medicine Research Institute (HARI)
3-2-1 Hotarugaike-nakamachi, Toyonaka, Osaka, 560-0033 Japan
E-mail: nj00ot@kmj.biglobe.ne.jp
Keywords: chronic pain, nociceptive pain, neuropathic pain, antidepressants,acupuncture and moxibustion treatment, autonomic nerve

Patients of nociccieptive pacn as well as
cihroncci pacn due to neuropathcci pacn andpsycihogencci pacn are cncireascng. In particiular, pacn generated afer surgery cnvolves
tenscon and emotion of the sympathetici
nerve, so ct cs dcfciult to ciontrol wcth
drugs. In thcs paper, I wcll report on
cihroncci pacn that aciupunciture and moxcbustion treatment cs thought to be efecitive.
In ancicent era, people made a physcologccial cnterpretation that pacn would leadto the bracn through nerves, and sensed
the pacn as a sensation. Currently ct cs not
only a scmple pacn but also an unpleasantsensation sucih as bcterness and an emotional expercencie [1,, 2].. Pacn cs cilassciedby sourcie. Pacn due to nociccieptive pacn
(somatici pacn, vcscieral pacn), neuropathccipacn (pacn due to nerve cnjury, pacn wcthout nociccieptive stimulus), psycihogencci
pacn (uncionscicous psycihologccial statesucih as anxcety or anger It ciauses pacn)[13.. Reciently, ciases of ciomplacncng of
cihroncci pacn due to neuropathcci pacn, psycihogencci pacn and the lcke are cncireascng.
Chroncci pacn cs deined as pacn associcatedwcth a progresscve nonciancierous dcseasewcth pacn lasting longer than expecited fortreatment.

The boundary between aciute pacn
and cihroncci pacn cs dcfciult to deine.
Aciute pacn cs ciaused by nociccieptor excictation. In the ciase of refracitory cn cihroncci
pacn, ct cs ciaused by a funcitional cihange cn
the cientral nervous system. The transction
area durcng thcs percod cian not be deined. In thcs transction area, cf the ciauseof pacn cs taken as the excictement of thenociccieptor, ct cs cmportant to determcne
the approprcateness of the cntervention
method or the therapeutici treatment
method.
The deinction of cihroncci pacn cs ambcguous. There are many ciases of transction from aciute pacn. Neeuropathy cs not
ciured, harmful stimulus may be the ciauseof pacn. When funcitional cihanges cn thecientral nervous system ociciur, cihroncci
pacn wcll ociciur even cn one month. Dcagnoscs of cihroncci pacn beciomes more dcfciult cf multiple facitors sucih as psycihogencci and socical facitors are cnvolved.
The pathogenescs of cihroncci pacn cs
dcferent between nociccieptive pacn andneuropathcci pacn [14, 5.. In the ciase of nociccieptive pacn ct cs cnfammatory pacn
throughnociccieptors.
Infammationciaused by tissue cnjury releases pacnful
substancies, resulting cn ciontinuous spon-Hotal Tradctional Orcental Medccicne Leters, Vol.2], Neo.,, pp.,-4, 2]0,5(C) 2]0,5 HARI,HOTAL TRADITIONAL ORIENTAL MEDICINE LETTERS, VOLUME 2, NUMBER 1
taneous pacn. In addction, sensctiiation of
nociccieptors results cn hyperalgesca (allodynca).
The mecihancsm of nociccieptor sensctiiation cs the phosphorylation of TRPV ,(Transcent Recieptor Potential Vancllocd ,)cihannel, whccih cs a noxcous stimulatory
recieptor of the con cihannel. In the ciase ofneuropathcci pacn, there was prevcously agermcnation theory of Aβ nerve ibers
from the dorsal horn of the spcnal ciord. In
recient years, gene expresscon cn dorsal
root ganglcon ciells due to cnput cncirease
from prcmary aferent nerve aciciompanycng nerve cnjury, phosphorylation ofsynapse con cihannel type glutamate recieptor NeMDA (Ne-methyl -D-aspartici Acicd)
recieptor. Acitivation of mcciroglca cn thedorsal horn of the spcnal ciord, and otherfuncitional cihanges have been revealed.
Based on the above-mentioned new
knowledge about pacn, ct cs neciessary tocionscder the analgescci efecit by aciupunciture and moxcbustion therapy.
Pacn cs an unpleasant sensory emotional expercencie associcated wcth substantial or potential cnjury of the tissue.
Reciently, knowledge on emotional expercencies and so on has cncireased, and approacihes to pacn based on sensory emotional expercencies have been made. Pacn
cs ciaused by free nerve endcngs and polymodal recieptors. Polymodal recieptors
tend to ciause pacn beciause they respondto varcous stimulc. In addction to TRP(Transcent Recieptor Potential) cihannels,
polymodal recieptors that respond to BK(Bradykcncn), PG (Prostaglandcn), and Cytokcne are B2]/B, and EP/IP. On the other
hand, there cs a problem that people whoare cnjured cn TrkA recieptors reaciting to2015

NeGF (Neerve Growth Facitor) do not feelpacn [16..
Afer surgery, pacn may ciontinue for along time afer surgery. Scncie there cs a
posscbclcty of thrombus formation as a
ciause of pacn, percoperative anticioagulation therapy cs admcncstered afer surgery
to admcncster anticioagulant. In the management of aciute pacn, self-adjusted analgesca method PCA (Patient Controlled
Analgesca) was the irst cihoccie until now.
However, as the adverse event cn thenerve blocik, there were the most reports
and ct was a problem [16.. A method tosolve the problem of PCA cs epcdural selfregulating analgesca method PCEA (Patient Controlled Epcdural Analgesca). PCEAcs to admcncster a prescircbed amount ofan analgescci cn small cncirements to theepcdural spacie by presscng a swctcih by apatient. In the past, PCEA was the irst
cihoccie afer surgery, but reciently PCA admcncstered IVPCA (Intravenous PatientControlled Analgesca) under systemcci admcncstration of opcocds cs cmplemented.
The patient presses the buton when hefelt ct hurts. Devccies were developed toautomaticially cnjecit opcocds when butonsare pressed.
The problem cs expenscve. PCEA cs good cn
ciases of pacn durcng body movements or
early postoperative days, but IVPCA cs theirst cihoccie beciause IVPCA also has thesame efecit as PCEA for resting pacn.
It has reciently been found that neuropathcci pacn cs cnvolved cn cihroncci pacn patients wcth nociccieptive pacn. Reciently, themecihancsm by whccih cnfammation
cihanges cnto neuropathcci pacn has beenrevealed. When the cnfammation prevacls
and a sustacned pacn scgnal cs cnput to theHotal Tradctional Orcental Medccicne Leters, Vol.2], Neo.,, pp.,-4, 2]0,5(C) 2]0,5 HARI2]

HOTAL TRADITIONAL ORIENTAL MEDICINE LETTERS, VOLUME 2, NUMBER 1nerve, the nervous system aciqucres hypersensctivcty as an error. Aciqucrcng hypersensctivcty means to cireate a sctuationthat cs easy to reciogncie as pacn. Chroncci
pacn ciaused afer perscstencie of cnfammatory pacn cs thought to be aciciompanced by neuropathcci pacn. Therefore, atreatment requcrcng both nociccieptive pacn
and neuropathcci pacn cs needed. Scncienon-sterocdal anti-cnfammatory drugs
NeSAIDs have no efecit cn the treatment ofneuropathcci pacn, new drugs have beendeveloped. In the Uncted States, pregabalcn was cilcnccially adapted from ,0 years
ago, but cn Japan ct was adapted from ive
years ago (trade name Lyrccia). Pregabalcn
suppresses pacn by cnhcbcting the transmcsscon of pacn [17..
The mecihancsm of acition of pregabalcn cs as follows. Neormally, cnformation
cs transmcted from the percpheral nerve
termcnal to the dorsal horn nerve of thespcnal ciord. Extraciellular Ca cons from cialcicum cihannels are taken up cnto nerve
ciells at nerve endcngs. Neeurotransmcter
vescciles ciontacncng glutamate are released
cnto the recieptors to cionvey cnformationof pacn. In the ciase of neuropathcci pacn,
Ca cons enter the nerve ciell by cihannel
opencng even wcth slcght pacn cnformationfrom the percphery. Therefore, a large
amount of neurotransmcter cs released,
the scgnal cs amplcied, and cnformation cs
transmcted as strong pacn. Pregabalcn adheres to the Ca cihannel and suppresses
the opencng of the Ca cihannel. Therefore,
even when cnformation cs transmcted,
neurotransmcters are not released beciause Ca cs not taken cnto nerve ciells. Pregabalcn was orcgcnally used as an antispasmodcci agent, but ct was found to have efciaciy cn the dorsal horn of the spcnal ciord,2015

and ct began to be used. Scde efecits cncilude drowscness and decilcncng cioncientration, and wandercng cn the elderly. Manyof the neuropathcci pacn cs cntracitable cnnature, so even wcth pregabalcn pacn ciannot be ciompletely taken. Therefore, ct cs
cmportant to cmprove qualcty of lcfe (QOL)
and bascci acitivcties neciessary for normal
dacly lcfe ADL (acitivcties of dacly lcvcng)
rather than ciompletely elcmcnating thepacn.
Evaluation methods cncilude the followcng. As evaluation of pacn ctself, there
are VAS (vcsual analog sciale), NeRS (Neumerccial Rating Sciale), Facie sciale, MciGcll
Pacn Questionnacre, Neeuropathcci Pacn
Scireencng Questionnacre. In the acitivcty
evaluation, there are BPI (Brcef Pacn Inventory), PDAS (Pacn Dcsabclcty Assessment
Sciale), and RDQ (Roland-Morrcs Dcsabclcty
Questionnacre). In psycihologccial evaluation, there are PCS (Pacn Catastrophcicng
Sciale), HADS (Hospctal Anxcety and Depresscon Sciale), BDI (Becik Depresscon Inventory), POMS (Proile of Mood States),
STAI (State Tract Anxcety Inventory).
I wcll dcsciuss and cioncilude cihroncci
pacn from the above results. Chroncci pacn
cs thought to have ciomplcciations ciaused
not only by neuropathcci pacn, but also by
decireascng dopamcne and decireascng acitivcty cn the cierebral nucileus aciciumbens
regcon cn the desciendcng ciontrol system.
In addction, pacn management cssues sucih
as the rcsk of epcdural blocik are racsed. In
particiular, scncie pacn cs cnvolved cn tenscon
and emotion of the sympathetici nerve, ct
cs dcfciult to ciontrol wcth drugs. Neew
knowledge has been proposed agacnst thecionventional cdea cientered on cnfammation, and lcmctations and problems of ciur-Hotal Tradctional Orcental Medccicne Leters, Vol.2], Neo.,, pp.,-4, 2]0,5(C) 2]0,5 HARI3HOTAL TRADITIONAL ORIENTAL MEDICINE LETTERS, VOLUME 2, NUMBER 1
rent Western medccicne treatment havebeen cilarcied.
Regardcng drug treatment, blocik cnjecitions are ciarrced out for neuralgca sucih
as shcngles (herpes). For cnterciostal nerve
blocik, pregabalcn cs used. Beciause pregabalcn cs a drcnkcng medccicne, ct cs prescircbed cn varcous ciases to blocik pacn cnvarcous parts. The aciciumulation of evcdencie on the synergcstici efecit of pregabalcn and aciupunciture and moxcbustion
treatment cs cmportant.
Psycihologccial facitors cncilude ciognctive
bcas and psycihosocical facitors. There are
psycihosocical facitors based on ciognctive
bcas other than organcci facitors as reasonsfor pacn cihronccicty. Therefore, ct makes
treatment dcfciult. Rather than acmcng at
elcmcnating pacn, ct cs cmportant to take a
vcewpocnt other than pacn from aciademcci
exercicse treatment, sucih as beciomcng
able to do somethcng that ciould not bedone, docng what you cian not do.
There are cncireascng ciases of ciomplacncng of not only nociccieptive pacn but
also cihroncci pacn due to neuropathcci pacn
and psycihogencci pacn. In the ciase of neuropathcci pacn, gene expresscon cn dorsal
root ganglcon ciells due to cncireased cnput
from prcmary aferent nerve associcatedwcth nerve cnjury has been revealed. Anticnfammatory drugs are used as analgesccis, but reciently analgescci treatment
uscng antiepcleptici drugs and antidepressants has beciome cmportant. Beciause patients wcth cihroncci pacn of nociccieptive
pacn ciontacn neuropathcci pacn, pregabalcn(Lyrccia) cs prescircbed for cnhcbcting pacn bycnhcbcting pacn transmcsscon. Based on thcs
new indcng cioncierncng pacn, ct cs cmportant to aciciumulate the evcdencie of anal-2015

gescci efecit on these pacn by aciupuncitureand moxcbustion therapy.
[1,. Kaiuo Maruyama, The way of thcnkcng of pacn, Neankodo, 2]0,4.
[12]. Neatsu Koyama, Bascci knowledge of pacn and analgesca, GcjutsuHyohron, 2]0,0.
[13. Ecjc Furuya, Toyo Therapy Assocication edcted Textbook Aciupunciture
Theory[14. Neobuo Neara, Toyo Therapy Assocication edcted Textbook Clcnccial
Medccicne General Edction 2]nd edction.
[15. Neobuo Neara, Toyo Therapy Assocication edcted Textbook Clcnccial
Medccicne Detacled Exposction 2]nd edction.
[16. Syuccihc Neosaka, The Japan Socicety of Aciupunciture and Moxcbustion
Kansac Brancih Semcnar A, Osaka, Sep. 2]0,5.
[17. Yohjc Fukaiawa, The Japan Socicety of Aciupunciture and Moxcbustion
Kansac Brancih Semcnar A, Osaka, Sep. 2]0,5.

(Reciecved , Deciember 2]0,5)

Dr. Neobuyukc Otsuka
He graduated from Tohoku Uncverscty cn ,985 and ciompleted the irst
half term of docitoral ciourse of Tohoku Uncverscty graduate scihool cn,987. He was awarded docitor degree cn ,997 from Tohoku Uncverscty.
He establcshed Hotal Ancicent medccicne Researcih Institute (HARI) cn,999. Neow, he cs enrolled at Mecjc scihool of orcental medccicne from2]0,4. He cs engaged cn researcih on orcental medccicne sucih as tradctional
Chcnese medccicne, aciupunciture and moxcbustion, qcgong etci.

Hotal Tradctional Orcental Medccicne Leters, Vol.2], Neo.,, pp.,-4, 2]0,5(C) 2]0,5 HARI4