Ultrasound Or Ultra Bullshit?

When I was doing postgraduate studies in Adelaide back in 2003, I was fortunate to have David Butler as one of our tutors teaching Pain Sciences. He also introduced us to the term 'ultra bullshit' when it came to what he thought about the effectiveness of using ultrasound to treat patients. Especially those patients with chronic pain.

For those of you using therapeutic ultrasound, please do not be offended. I'm not suggesting that you cannot, should not or better not be using it, I'm just saying that we almost never use ultrasound in our clinics to treat patients.

However, I've been receiving therapeutic ultrasound almost daily since my T4 spine fracture last month. Why the sudden change? There have been studies showing that pulsed ultrasound can accelerate bone union by up to a week. I'm up for anything that helps my fracture heal better and faster!

Therapeutic ultrasound appears to effectively heat tissues (muscles, connective tissues etc) but research has not established the ideal temperatures for tissue benefit or tissue damage. Current research also suggests that therapeutic ultrasound will not help pain reduction, delayed onset of muscle soreness (DOMS) or iontophoresis (deliver medicine under the skin), BUT it does appear to facilitate fracture healing. That previous sentence you read was 'a sight for my sore eyes'!

So my beloved wife has been helping daily with my ultrasound regime, although she does delegate the tasks occasionally to my boys as she says it's terribly boring holding on to the ultrasound device.

Looking forward to my next MRI to see how my fracture has healed.

Reference

Eberman L, Schumacher H, Niemann AJ et al (2013). Research Evidence For Therapeutic Ultrasound Effectiveness. Int J Ath Trg. 18(4): 20-22. DOI: 10.1123/ijatt.18.4.20. * Thanks to Byron who got me the article.

Phantom Limb Pain

How many of you have heard of phantom limb pain? The physiotherapists reading this definitely have, but what about my other readers?

Phantom limb pain (PLP) is the feeling of pain in a body part that does not exist (usually amputated because of an  accident or diabetes). Amputees often get phantom limb pain. After amputating a foot, arm or leg from a person, the brain still has that foot, arm or leg mapped. It is not totally clear how and why a person without the physical limb can still have sensations or pain.

Interestingly, it does not just happen in the arms and legs. Phantom breasts, penises and tongues have been reported too (Davis 1993).

Other than pain, patients say sometimes they feel 'it' tingles or itches too. Often PLP symptoms become worse when the person becomes stressed.

PLP tells us about the representation or map of the limb (the 'virtual limb' inside the brain). This is known as the homunculus. Those of you who attended my Kinesio Taping or Floss Band courses would have already heard of this.

The homunculus

It's been a while since I've treated an amputee, but I read about this very interesting case of a woman with PLP. This woman, named RN in the study was born with only three fingers on her right hand. When she was 18, she got into a car accident and several bones in that right hand was broken. Six months later, her doctors decided to amputate that hand.

After amputation, RN reported having pain as though her hand was still there. You would expect her pain to be in the hand with the three fingers she lost. However, she reported feeling five fingers on her painful phantom hand. And they were not five normal fingers. She said her thumb and index finger felt shorter than the rest, but there was definitely five fingers.

RN lived with this phantom hand for many years before seeking help. She was 57 before she saw Dr Ramachandran (a pioneer for phantom limb research). Like what we learnt from David Butler, Dr Ramachandran treated her with the mirror box. After the mirror training, RN reported that her two smaller fingers had grown to normal size. She now feels that she had a normal right hand, that happened not to exist.

David Butler and the mirror box

Super interesting right? RN never had a normal right hand. You would think that her brain wouldn't have the map (or homunculus) to tell her how it may feel like.

To quote Dr Ramachandran : "The amputation of her hand appears to have disinhibited these suppressed finger representations in her sensory cortex and allowed the emergence of phantom fingers that had never existed in her actual hand."

In other words, the brain has a ready-made map (or homunculus) for a normal hand, that was tweaked to accomodate RN's condition. Once the physical hand was amputated, that map was restored.


*pictures taken with my iPhone XS from David Butler's Explain Pain book.

References

Davis RW (1993). Phantom Sensation, Phantom Pain And Stump Pain. Archives Phy Med Rehab. 120: 1603-1620.

McGeoch PD and Ramachandran VS (2012). The Appearance Of New Phantom Fingers Post-amputation In A Phocomelus. Neurocase. 18(2): 95-97. DOI: 10.1080/13554794.2011.556128.

No Pain No Gain

Every now and then we get patients with chronic pain in our clinic, so I was really interested when I saw this case report about a 71 year old woman who feels no pain. I was hoping to find ways to really help these chronic pain patients.

She was found to have two notable gene mutations, FAAH-OUT  which researchers know to have links to pain sensitivity. The second was a microdeletion in the FAAH gene which reduces pain sensation, accelerated wound healing, reduced anxiety and enhanced fear-extinction memory.

This lady sought treatment for a hip issue and was found to have severe degeneration in the hip despite feeling no pain. When researchers looked into her case file, they found that she never reported experiencing pain or needed pain medication after surgery. Even during childbirth, after broken bones and cuts. She was burnt once, but only realized it after smelling her flesh burning!

I was then thinking, if an elite athlete had that sort of mutation and felt no pain, would that be a real major performance enhancer? That would surely not be considered as doping.

Think of how it would affect you if you were running and attempting to beat your personal best in the marathon. If you didn't feel any pain, nor the burn of accumulating lactate in your muscles when you were clicking out each kilometer at your goal pace. Surely you would be able to keep pace to beat your target time.

After thinking about it for a while, I realized that it is not possible. If you experience no pain while training, it would definitely expose you to injuries. Pain is necessary during training to help provide feedback and modulation and of course for adaptation to training.

During races, your performance is affected because pain impacts pacing. If you can't feel pain, you wouldn't know how to back off, when to slow down. You will purely be running by numbers (time) and not physiology.  That means you wouldn't know when to rest. Over training will become common. Mild injuries will then become severe.

Like what I always tell the athletes that I treat, "make pain your best friend". If you can tolerate pain, you will be able to perform your best.


Reference

Habib AM, Okorokov AL, Hill MN et al (2019). Microdeletion In A  FAAH Pseudogene Identified In A Patient With High Anadamide Concentrations And Pain Sensitivity. Br J Anaesthesia. DOI: 10.1016/j.bja.2019.02.019

Signed by David Butler himself in 2003.