Ray D’Alonzo, Ph.D., is Manager of Doctoral Recruiting & University Relations and a former Associate Director of Research and Development at Procter & Gamble Pharmaceuticals where he has worked for 30 years.  He has led research programs in bone metabolism, infectious disease, respiratory disease, arthritis, and nutrition and has published scientific papers on a wide variety of topics from the chemical composition of fats and oils to the pharmacoeconomics of osteoporosis. Dr. D’Alonzo is the recipient of the Chancellor’s Medal from the University of Massachusetts, Amherst, in part, for his contributions to the development of new pharmaceutical agents. As both a patient and scientist, he has made a personal effort to increase the awareness of Chiari in the health care sector and to assist others afflicted with the syndrome.  He has published the story of his personal struggle with Chiari in a book, Contents Under Pressure, with 100% of royalties going towards Chiari education, awareness, and research programs.

January 31, 2008 --     

Dare I “Suggest” Hypnosis? 

Chiari is often associated with chronic pain that is believed to be neuropathic in nature.  Neuropathic chronic pain is difficult to treat.  Medications that regulate neurotransmitters such as the antidepressants, particularly Elavil^® (amitriptyline), are often prescribed.  Certain sedatives like Klonopin have also been found as helpful.  Newer medications such as Lyrica^® are rapidly being adopted.  Lyrica^® has been approved by the FDA specifically for neuropathic pain associated with diabetic peripheral neuropathy.  However many Chiari patients report these medications to be ineffective or marginally effective and many can not tolerate their side effects.  As a result, many patients turn towards alternative therapies to seek relief.

Chronic pain takes a significant toll on the patient's quality of life.  It can negatively affect the patient's ability to perform physical work.  It can cause the patient to withdraw from family and other social activities.  It often pushes patients into a state of clinical depression

Because chronic pain is such an important and inescapable aspect of the lives of so many Chiari patients and many seek alternative therapies in hopes to improve their function, when the executive director of Conquer Chiari suggested that I write about hypnosis and its potential to treat or manage chronic pain, I agreed.

I have written about other alternative treatment modalities in this column in the past usually by researching the medical literature and examining the scientific merit of published clinical trials.  Proving that a treatment modality is actually effective is no easy task.  Anecdotal reports (personal testimonies and the like) do not constitute proof.  Publications describing individual case studies are better but likewise insufficient because what works for a single individual may not work for others.  Proof is best offered in the form of well designed and controlled clinical trials or studies.  It is also important to understand that many trials are poorly designed or too small to accept as proof.  Further, the findings from a well designed and controlled study should be confirmed by additional studies.  Reproducibility of findings across multiple studies is very important.  With this in mind, I have examined such treatments as Reiki¹ and cranial sacral therapy² for example.

In preparing to look at hypnosis, I thought it might be helpful to first look at a treatment that is well accepted as proven, namely the use of statins in lowering blood cholesterol levels.  If one does a search of the medical literature for controlled randomized clinical trials on statins in hypercholesteremia, over 1,700 papers will immediately appear.  This illustrates the extent to which this class of medications has been studied.  When one does a similar search on hypnosis in neuropathic pain, no papers appear.  When that search is “relaxed” to find any type of clinical trail (not necessarily controlled or randomized) on hypnosis and neuropathic pain, again no papers appear.  When the search is further relaxed or broadened to look for controlled randomized clinical trials on hypnosis and pain as opposed specifically to neuropathic pain, 95 papers appear.  Not all of these papers actually deal with hypnosis.  Many deal with related treatments/techniques such as biofeedback, cognitive coping, relaxation therapy, guided imagery, and non-hypnotic suggestion.  Further, some of these papers do not actually deal with pain.  Some deal with healing such as the rate of bone fracture healing.  So the number of papers reporting on controlled randomized clinical trials on hypnosis and pain is much smaller than 95 and of those papers there is a wide variety of patients and sources or types of a pain.  Patient populations studied range from young children to senior adults.  Pain associated with everything from irritable bowel syndrome to cancer to burns are reported.  Many of the studies fall short of the preferred design of including a placebo-controlled group.  It is more common to see studies that compare hypnosis to positive-controlled groups (such as a pain medication) as it can be unethical to administer a placebo only to patients in severe pain.

Another problem has to do with the patient populations studied.  All clinical studies have criteria by which patients are included or excluded.  In studies where hypnosis is employed as the treatment modality, patients are often included on the basis of their susceptibility to hypnotic suggestion.  So it is important to recognize that the results achieved can not be applied to a more general population and certainly not to individuals who are resistant to hypnotic suggestion.  Because of these complications and many more not mentioned, it is not possible to determine or even speculate if hypnosis can be effective in reducing the neuropathic pain associated with Chiari.

Nevertheless, it is not possible to say that it is not effective either and there exists a handful of studies reported in the literature that are well designed suggesting that hypnosis may be effective in managing other types of pain.  One of the better studies conducted at Stanford University School of Medicine evaluated hypnosis as a treatment to reduce both pain and frightening in children undergoing a common invasive radiographic procedure known as voiding cystourethography or VCUG³.  While this study was conducted in a pediatric population for an acute pain experience, it was executed by a prestigious research organization and was well designed.  The study randomized 44 children into one of two groups, one group received hypnosis, the other routine care (hospital provided education, relaxation therapy and recreation).  All children included in the study had a least one previous VCUG.  Measured parameters such as pain, discomfort, and anxiety were obtained by patient self-assessment as well as by parents and medical staff assessments.  Upon completion of the study, parents reported that children in the hypnosis group compared with those in the routine care group were significantly less traumatized compared with their previous VCUG procedure.  Observational ratings of typical distress levels during the procedure were significantly lower for children in the hypnosis condition compared with those in the routine care condition.  Further, medical staff reported a significant difference between groups in the overall difficulty of conducting the procedure, with less difficulty reported for the hypnosis group and total procedural time was significantly shorter by almost 14 minutes for the hypnosis group compared with the routine care group.

The significance of this study in hypothesizing whether hypnosis would be of benefit to Chiari patients presenting with neuropathic chronic pain is completely unknown of course but when other more main stream treatments fail a justification may exist to explore hypnosis particularly if the Chiari patient considers him or herself susceptible or open-minded to suggestion.

It is fascinating to note that there are 3 times as many review articles on hypnosis and pain then there are articles reporting clinical trial results.  The medical literature may therefore be dominated by opinion on this matter rather than well derived data.  This is not unusual but disappointing to some extent.  Hypnosis will likely never be proven as an effective therapy for pain against the same sort of rigid standards that drugs are for example.  The studies required to do so would be expensive and no company, government, or academic research organization is likely to make such an investment at this point. 

It is important in closing to mention that whenever an alternative treatment is sought the patient needs to be aware that practitioners may not be licensed or actually have the proper training so ask your doctor or even your health insurance representative for a recommendation.

 ¹ Does Reiki Deliver The Healing Touch?
  Does Reiki Deliver The Healing Touch (Part II)?

 ² Weighing In On Cranial Sacral Therapy

³ Pediatrics. 2005 Jan;115(1):e77-85.

-- Ray D'Alonzo

 ** If you would like to share your comments, thoughts, or ideas with Ray,  please send them to dalonzo.rp@fuse.net.  Due to the volume and nature of email received, individual responses are not possible. **

[Ed. Note:  The opinions expressed above are solely those of the author.  They do not represent the opinions of the editor, publisher, or this publication.  Mr. D'Alonzo is not a medical doctor and does not give medical advice.  Anyone with a medical problem is strongly encouraged to seek professional medical care.]    
 

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