Significance of pain management in Homoeopathy

Dr Puneet Kumar Misra

Abstract
Pain is the first indication of discomfort which earlier and actively   perceive by the human and need to resolve rapidly with gently and it is the one of the main   cardinal signs of the inflammation. Since beginning of homoeopathy believe in the totality of the symptoms for the treatment. it is also true for the assessment of pain because the pattern of pain is the chief indication of disorder therefore totality of pain are also needed    for disorder and its treatment .materia medica is the sources of totality in the medicinal substance    and repertory is the sources of its intensity in the different .so pain remain a significant factor in determining   the condition of disorder as well as the patient for treatment,

DEFINITIONS
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This definition recognizes that pain may occur in the absence of ongoing tissue damage, such as fibromyalgia or phantom limb pain. One implication of this construct is the assumption that pain is always subjective; hence a patient’s report of pain should always be accepted at face value in the absence of evidence to the contrary .5

SIGNS OF INFLAMMATION
The Roman writer Celsus in 1st century A.D. named the famous 4 cardinal signs of inflammation as: i) Rubor (Redness); ii) Tumor (Swelling); iii) Calor (Heat); and iv) Dolor (Pain).1

Particular gestures useful in analysing specific pain symptoms
■ A squeezing gesture to describe cardiac pain ■ Hand position to describe renal colic ■ Rubbing the sternum to describe heartburn ■ Rubbing the buttock and thigh to describe sciatica ■ Arms clenched around the abdomen to describe mid-gut colic2

 List of clarifications for a complaint of pain
■ Site ■ Radiation ■ Character ■ Severity ■ Time course ■ Aggravating factors ■ Relieving factors ■ Associated symptoms2

 CLINICAL PEARL
A useful mnemonic when taking a pain history is SOCRATES: ● Site ● Onset (sudden or gradual) ● Character ● Radiation ● Associations (other symptoms or signs) ● Time course ● Exacerbating and relieving factors ● Severity3

 Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. It is one of the most common symptoms for which people seek health-care advice. Our understanding of the mechanisms of pain has evolved considerably from Hippocrates’ suggestion in 450 BC that pain arose as a result of an imbalance in vital fluids. We now know that pain is a complex symptom that is influenced and modified by many social, cultural and emotional factors. The sensation of acute pain that occurs in response to inflammation or tissue damage plays an important role in protection from further injury. Chronic pain serves no useful function but results in significant distress and suffering for the patient affected, as well as having a wider societal impact.4

Genetic determinants of pain perception
There are marked ethnic and individual variations in how people respond to painful stimuli and studies in twins have estimated that the heritability of CWP ranges between 30% and 50%. In the general population, the individual variants in response to pain and perception of pain are most likely due to a complex interaction between genetic and environmental influences. Few variants have been identified with robust evidence of association with CWP. Several rare syndromes have been described, however, in which insensitivity to pain or heightened pain responses occur as the result of a single gene disorder. Most are due to mutations affecting ion channels that play a key role in neurotransmission, but other causes include mutations in the NTKR1 gene, which encodes the receptor for nerve growth factor, and mutations in the PDRM12 transcription factor, which is involved in neuron development.4

Investigations
Pain can be a presenting feature of a wide range of disorders and the first step in evaluation of a patient with pain should be to perform whatever investigations are required to define the underlying cause of the pain, unless this is already known. However, with most chronic pain syndromes, such as fibromyalgia, complex regional pain syndrome and CWP, investigations are negative and the diagnosis is made on the basis of clinical history and exclusion of other causes. Specific investigations that are useful in the assessment of selected patients with chronic pain are discussed below.4

Magnetic resonance imaging
Magnetic resonance imaging (MRI) can be helpful in the assessment of an underlying cause in patients with focal pain that follows a nerve root or peripheral nerve distribution. Imaging is seldom helpful in individuals with CWP.4

Blood tests
Blood tests are not generally helpful in the diagnosis of chronic pain, except in patients with peripheral neuropathy; in this case, a number of blood tests may be required to investigate.

Quantitative sensory testing
Quantitative sensory testing can be helpful in the detailed assessment of patients with chronic pain. A simple set of tools can be used in the clinical setting. Lightly touching the skin with a brush, swab or cotton-wool ball can be used to test for abnormalities of fine touch. This may include allodynia, where a normally non-painful stimulus is perceived as painful. Assessing the patient’s response to a pin-prick can be used to test for abnormalities in mechanical hyperalgesia. Finally, touching the patient’s skin with warm and cool thermal rollers can be used to test for abnormalities of thermal sensation. An unaffected area of skin should be tested first, to establish normal sensation, before testing the affected area.4

Nerve conduction studies
Nerve conduction studies can be helpful in demonstrating and quantifying a definitive nerve lesion, either peripherally or centrally. They can be used to help differentiate between central and peripheral neuropathic pain. They do not, however, effectively examine small nerve fibre function.4

Nerve blocks
Performing a nerve block with infiltration of a local anaesthetic such as 1% lidocaine can be used diagnostically, in assessing whether a pain syndrome is due to involvement of a specific nerve or nerve root. Where inflammation and or swelling may be contributing to the underlying pain – for example, if there is compression of a nerve root – then a mixture of local anaesthetic and depot glucocorticoid may be helpful in alleviating pain. Nerve blockade can also be used to determine whether more radical therapies, such as nerve ablation, might be helpful in controlling pain particularly that related to cancer.4

Pain scoring systems
Various questionnaires and other instruments have been devised to localise pain, rate its severity and assess its impact on quality of life.  Similarly, other methods have been developed with which to assess the severity of pain using verbal, numerical and behavioural rating scales. Visual scoring systems employing different facial expressions may be of value in paediatric patients and those with cognitive impairment. Documenting changes in pain scores using questionnaires can be helpful in indicating to what extent drug treatments have been successful and can reduce the time taken to achieve pain control. 4

Instrument used in the assessment of pain and its impact Comments

Brief Pain Inventory Developed for use in cancer pain, validated and widely employed for

Chronic pain; based on 0–10 ratings of pain intensity and the impact of pain on a range of domains,

Including sleep, work and enjoyment of life

Pain Detect, s-LANSS, DN-4 A number of screening questionnaires to aid diagnosis of neuropathic pain

Pain Catastrophising Scale Developed to assess individual levels of catastrophising, encompassing three different domains: helplessness, rumination and magnification

Tampa Scale of Kinesiophobia Measures how much an individual is fearful of movement

Pain Self-efficacy Questionnaire assesses individual beliefs about self-efficacy in the context of chronic pain, and how this impacts on function

Visual analogue scale (VAS) Patient marks pain intensity on a horizontal line

Localisation of pain Body chart, allowing the patient to indicate where pain is situated

Beck Depression Inventory Assesses emotional function

SF-36/EQ-5D Assesses health-related quality of life (DN-4 = Douleur Neuropathique questionnaire; EQ-5D = EuroQol 5-Domain questionnaire; SF-36 = Short Form 36; s-LANSS = self-completed Leeds Assessment of Neuropathic Signs and Symptoms) 4

Chronic pain syndromes
Chronic pain is a feature of several recognised syndromes, which are

Neuropathic pain
Neuropathic pain is defined as ‘pain associated with a lesion or disease of the somato sensory nervous system’. Neuropathic pain may be acute, such as in sciatica, which occurs as the result of a prolapsed disc, but is most problematic when it becomes chronic. Neuropathic pain causes major morbidity; in a recent study, 17% of those affected rated their quality of life as ‘worse than death’. The clinical features of neuropathic pain are summarised below 4

Spontaneous pain No stimulus required to evoke pain

Positive sensory Disturbance Light touch painful Pressure painful Increased pain on pin-prick Cool and warm Temperatures painful Dynamic allodynia Punctate allodynia Hyperalgesia Thermal allodynia 4

Negative sensory disturbance Numbness Tingling Loss of temperature sensitivity Loss of sensation Paraesthesia 4

Other features Feeling of insects crawling over skin Affected area feels abnormal Formication Dysaesthesia 4

The diagnosis is easily missed and so careful assessment is vital, in order to make the diagnosis in the first place and then to direct management appropriately. It is important to recognise the negative impact of neuropathic pain on quality of life, which has been shown to be greater than with other types of chronic pain. As a result, appropriate support and multidisciplinary management should always be considered in addition to pharmacological therapies. 4

Complex regional pain syndrome
Complex regional pain syndrome (CRPS) is a type of neuropathic pain that affects one or more limbs. It was previously termed reflex sympathetic dystrophy (RSD), reflecting the fact the disease is thought to be caused in part by an abnormality in the autonomic nervous system. It is a rare syndrome, occurring in about 20 per 100 000 individuals, and is more common in females, typically presenting between the ages of 35 and 50. It is classified into type 1 CRPS, which may be precipitated by a traumatic event such as a fracture but is not associated with peripheral nerve damage, and type 2 CRPS, which is associated with a peripheral nerve lesion. The diagnosis is primarily clinical, with the current standard being based on the Budapest criteria, as outlined in below. 4

The Budapest criteria for diagnosis of complex regional pain syndrome (CRPS)

Sensory Allodynia to: Temperature Light touch deep somatic pressure Movement Hyperalgesia to pin-prick

Vasomotor Temperature asymmetry Skin colour change and/or asymmetry

Sudomotor Oedema Sweating change and/or asymmetry

Motor/trophic Reduced range of motion Motor dysfunction: Weakness Tremor Dystonia

Trophic changes: Hair Nails Skin

Homeopathic Point on the Pain on the basis of  Materia Medica and Repertory –  both  subject are  the fundamental stone  of the homoeopathy since origin , but description of disorder pattern in the both subject are different mentioned below.

Materia Medica   – In this subject medical properties of material (drug) is described without their intensity with association (concomitant or complementry , antidotes, inimical , follows well) of other few material (drug) .but after observation and makes the totality of the disorder medicinal properties of substance is clear for ex. Hypericum is good for peripheral neuropathic pain after injury ,Rhus tox is better for stiff joint pain, Arnica Montana pain in the traumatic injuries, Cactus grand in the constriction chest pain, abdomen pain in the mag phos and colocynthis, headache in the sanguinaria and spigelia  e.t.c.

Repertory
In this subject medical properties of material (drug) is described with their intensity and comparison to other in the form of 1+,2+,3+,4+,5+,. The pattern of compare the drug substance intensity is different types as per individual repertory with their writing pattern i.e. font of medicine name means in bold , small , italic ,roman e.t.c..

Sensations and complaints in general of Boenninghausen’s Therapeutic Pocket Book
Pain is mentioned in the different rubrics in the mentioned book and its Part . Benumbing Pain, bruised pain ,clamp like pain, festering, pain as from , gout-like pains, grinding pain, growing pains, jerking pain, labor like pains, oppressive pain (pinching & stricture),pain blunt, pain jumping from place to place ,paralytic pain, pressing (simple pain) , sensitiveveness to pain, shattering (broken to pieces) pain, shuddering pain (as from concussion) , sore pain (smarting), splitting pain (bursting asunder), strangling pain (constriction), thrusts (pushing pain), ulcerative pain, undulating pain, the above mentioned pain name is not on the basis of their origin pattern thats nomenclature is dependent on the explain the feel of it by patient during clinical observation .7

National Commission for Homoeopathy
The highest quality control institution  of quality education in homoeopathy  also focus on the  importance of the  pain ,therefore its second year BHMS  competency based dynamic curriculum which is effective from 2022-2023 in the subject of  practice of medicine start from  first topic is pain under main  heading clinic pathological evaluation of common signs and symptoms with miasmatic integration with topic breakup1) Pain : Pathophysiology ,types of pain ,2) chest discomfort ,3) abdominal pain 4) headache 5) back & neck pain . In the four hours under 16 knowledge and scholarship domain of competency up to the C1, C2, level as per Bloom’s domain / Guilbert’level . C means Cognitive Domain C1: Knowledge C2: Comprehension.

The different types of repertory are used in the homoeopathy, the number of rubric of pain in different repertory given in the table as per Hompath 11 Zomeo LAN 3.0.

Name of Repertory	Pain  rubric
Repertory of the homoeopathic Materia Medica  J T Kent	27411
The Concordance  Repertory of the Materia Medica  William D Gentry	19552
Repertory of Hering’s Guiding Symptoms of our Materia Medica Calvin B Kneer	10370
Boenninghausen’s Characteristics and repertory C M Boger	8393
Repertory to the more characteristic symptoms of the materia medica C Lippe	2337

Discussion

1.  Pain need to broad observation with clinical approach for final the origin and its treatment for the complicated as well as severe acute onset in the routine practice. While periodical occurs pain is mainly based on the pre onset state and circumstance for it precipitation,
2. Homoeopathy also focuses   on the totality of symptoms along with perfect picture of disease as per organon of medicine since the time of Dr Hahnemann it is also true for the pain narration.
3. Homoeopathy materia madica mainly described the area of action of the medicinal substance on the pain as well as their associated disorder,  and also the  conditions which controls or remove the complain  of patient
4. Repertory are provide the index of pain with grading of intensity in the  different medicinal substance ,as above mentioned in the table the hues rubric are found under the pain heading  ,it shows that pain covered a large part in the repertory also .

Conclusion
Removal or Control of the pain is the prime need of the patient as well as goal of the clinicians , it is the need of time that clinician is crystal clear for all about the pain including origin, path, cause behind the occurrence or aggravation, pattern of removal or subside   with duration i.e. perfect totality means   location, sensation, modalities and concomitants . this is  needful conditions for rapid gentle treatment with good association of repertory during repertorisation  and materia medica for prescribing totalities .

Reference

1. Dr Harsh Mohan, Textbook of Pathology 7^TH Edition Jaypee Brothers Medical Publishers (P) Ltd.2015. page 116
2. Sir Robert Hutchison .Hutchison’s Clinical Methods 24 Edition Elsevier Ltd 2018. page 05, 08.
3. E Noble Chamberlain Symptoms and Signs in Clinical Medicine, 13 edition 2010 Edward Arnold (Publishers) Ltd Page 05,10.
4. Davidson Sir Stanley. Davidson Principal & Practice of medicine. 24^TH Elsevier Ltd; 2018. Page 156-167
5. Dr LEE GOLDMAN. Dr ANDREW I. SCHAFER.  Goldman-Cecil Medicine 26 EDITION Elsevier Philadelphia 2020. page no 128-130
6. Harrison T. R. Harrison’s Principles of Internal Medicine. 21 Editions. By McGraw-Hill Education; 2022. page 91
7. T F ALLEN. Boenninghausen’s Therapeutic Pocket Book 16^Th impression 2018 B Jain Publishers(P) LTD . Page no 142-196
8. Second Year BHMS  Competency Based Dynamic Curriculum National commission for homoeopathy 5.4.1 Sr No 1,& 6.1.1 Pain HomUG-PM I 1.1 -1.16 Page 07 & 17-20.
9. Hompath 11 Zomeo LAN3.0 copyright 2016 Mind Technologies

Dr Puneet Kumar Misra
Reader (Practice of Medicine)
Govt Pt JLNHMC Kanpur