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Belief systems in the treatment of neuropathic pain

There are many misconceptions that may hamper the treatment of patients suffering neuropathic pain. These misconceptions are all parts of belief systems. Your belief system is the actual set of precepts from which you live your daily life, those which govern your thoughts, words, and actions. For a doctor these belief system are defining the way he explores medical problems, and how he treats and prescribes. Belief systems have a strong impact on behaviour! 

And perhaps even more important, clinicians’ personal belief systems, attitudes, and fears will directly influence the manner in which they and their patients respond to all the diverent modalities of pain management. The patient of course plays an important role too. His or her knowledge and beliefs about pain play a clear role in pain perception, function, and response to treatments. 

Belief systems create myopia!

Belief systems always create myopia. Regina Vink (2000) gives the following list of certain unhealthy belief systems of patients, related to pain:

  1. Pain is a part of life. I just need to bear it.
  2. I shouldn’t take my pain medication until I really need it or else it won’t work later.
  3. I don’t want to become an addict.
  4. I don’t want to get constipated so I’d better not take my pain medication.
  5. I don’t want to bother the doctor or nurse; they’re busy with other patients.
  6. If it’s morphine, I must be getting close to the end.
  7. My family thinks I get confused on pain medication; I’d better not take it. 

Belief system: Pregabeline should better not be taken in higher dosages 

These are just some belief systems, there are plenty, and each day in our clinic we hear some examples of belief systems, which probably have a negative impact on the efficacy and safety of prescribed drugs.

For instance, many patients fail to use proper dosing of drugs such as pregabeline, due to the fact that they fear the side-effects, which are so impressively described in the package insert. Much explaining is needed to convince patients to explore higher dose-ranges. Most patients want to stick with two times 75 mg, and that dose is very near the no effect dose. 

This misconception is related to numer 4 on the list of Vink.  

And hand in hand with misconceptions form the side of the patients, we find misconceptions in the head of the clinician. 

Scientific belief systems in neuropathic pain

Distal axonal degeneration is a hallmark of many neuropathies. Traditionally neurologists tended to think in a simpel degeneration-regeneration model. The celbody of each neuron, based on the functions of its residing nucleus, is key in regeneration, and all regeneration processes are anterograde. Failure of metabolic support for the cellbody causes an impairement in the function of the axon, due to the fact that the axon itself is poorly inhabited by ribosomes and mitochondia and thus the axon is totally dependent on support from its master, the cellbody.

In 1997 Spencer at all described the degeneration proces using an analogy of the farthest meaddow, which is the first to be drowned from water support, if the waterpump fails. These analogies and metaphors always play a big role in our understanding and our approach of scientific problems and clinical problems.   

The idea that axonal degeneration follows the metaphor of the last meaddow (‘letzte Wiese’) is totally not in line with recent findings. Actually it is nearly a mirror or inverse image of what probably happens in reality.[1]

It is not the cellbody, which is the victim of the metabolic assault, it is the axon itself, with its 1000 times greater volume of cytoplasm. The specific target in the axon is the retrograde transport of growthfactors, from the peripheral axon towards the cell body. This retrograde transport most probably forms the essence of survival of the neuron, and is the base of the  anterograde transport functions of the neuron. [2] 

So the proces of degeneration starts in the peripheral part of the neuron, and is not only or mostly steered by the ‘master’, the nucleus of the cell body, itself. This clearly is a paradigm shift for many neurologists, trained in cell biology as it was explained some years ago…

The nervous system as a train-rail station

In neurology some metaphors are burried in pictures. Here we see the immage of the nervous system as a train rail station with many train-roads. It is a picture I found in one of my old neurology books.

Quite a static picture, and difficult to bring in line with whatever modern ideas of plasticity and functionality.

Cleary these are powerful visual metaphors, and metaphors like these influence our thnking about what is possible and what is not possible in the treatment of neurological disorders and pain states. And not only our thinking…How do you think these metaphors will impact the patients ideas about there own complaints and symptoms, if they suffer from neuropathic pain?

zenuwen_treinstation.jpg

 

 

Jan M. Keppel Hesselink, MD, PhD, october 2010 

Sources 

Williams DA, Robinson ME, Geisser ME. Pain beliefs: assessment and utility. Pain 1994;59:71-78.

REGINA FINK. Pain assessment: the cornerstone to optimal pain management. BUMC Proceedings 2000;13:236-239 

Referentie

[1] Spencer PS, Sabri MI, Schaumburg HH, Moore CL. | Does a defect of energy metabolism in the nerve fiber underlie axonal degeneration in polyneuropathies? | Ann Neurol. | 1979 Jun;5(6):501-7.

[2] Ginty DD, Segal RA. | Retrograde neurotrophin signaling: Trk-ing along the axon. | Curr Opin Neurobiol. | 2002 Jun;12(3):268-74.