Dr. Bahram Jam, DScPT, MPhty, BScPT, CredMDT
The following insightful article was written by Dr. Bahram Jam, DScPT, MPhty, BScPT, CredMDT. We are thankful to him for his permission to reproduce the article here. You can read more about Dr. Bahram Jam and the Advanced Physical Therapy Education Institute (APTEI) at https://aptei.com/
I originally assessed Mrs. A, a 65-year-old lady in 1998 where she reported of significant global neck pain. Her x-rays showed typical degenerative changes that were blamed for her ongoing symptoms. After several weeks of physical therapy, she regained some neck mobility, but her symptoms mostly persisted. I felt that my interventions had failed. 😔
In 2002 I saw Mrs. A again reporting of bilateral knee symptoms. She reported little change in her neck pain in the past 4 years and in addition her knees were now problematic. Although she had some radiological evidence of degeneration in her knees, she was not yet a surgical candidate. I provided her with 6 weeks of physiotherapy treatments but she made minimal symptomatic improvements, and in the end, I recommended her to use a cane. She also received cortisone injections that were of little value. I felt that I had once again failed in my attempts to help this pleasant lady. 😔
In 2005 I saw Mrs. A again for her ongoing neck and knee pain but in addition, she reported low back pain that was limiting her walking. She specifically came back to see me as she felt I was caring and kind to her. Knowing the lack of response to my past physiotherapy interventions, I focused on functional movements and activities. I discussed with her the importance of taking her pain medications as prescribed by her physician and the importance of pacing. I provided her with various assistive devices to help with her activities of daily living. I provided her with knee braces that at least provided her with a sense of stability. Unfortunately making little change in her pain, I once again discharged her with a home program. 😔
In 2015 I saw Mrs. A again as she was brought in by her daughter for an acute wrist injury after falling off a chair. Mr. A was now 82 years old. Regrettably, Mrs. A had been diagnosed with advanced Alzheimer’s Disease (AD) 2 years earlier and she had no awareness of her surroundings and her family members. I was saddened when she did not remember me anymore. 😔
The most fascinating fact about Mrs. A was that since diagnosed with AD, she had gone off all her pain medications and no longer required a cane for ambulation. When I questioned Mrs. A on her knee pain, neck pain and low back pain, she reported being completely pain-free. Fascinated by this, I questioned her daughter that if she had heard her mother complain about any of her “old” symptoms in the past 2 years. Her daughter responded that since diagnosed with AD, she had been able to walk long distances without a cane, without her knee braces and no longer reported needing any pain medications.
Out of curiosity, I asked permission to evaluate her neck and back mobility. I was pleasantly surprised to notice that Mrs. A’s spine mobility was now within normal limits and most importantly comfortable. The same movements that were painful for over a decade were now pain-free!
I was intrigued. Could it be that all these years Mrs. A had centrally sensitized pain and now that she had developed AD, her brain had literally “forgotten” about her pain history? 🤔 Mrs. A could of course still feel acute pain which was clear following her recent wrist injury but she no longer felt all her “old” aches and pains.
I was blown away by what I had learned from Mrs. A, I rushed onto PUBMED and assumed I would be able to find several research papers on the topic of chronic pain amongst those with AD. To my surprise, it is an area that has received little attention to date. This is all I found that was relevant to my topic of interest.
General analgesic use is very low among nursing home residents with dementia1.
A study looked at 300 institutionalized seniors and found that analgesic consumption for chronic pain was significantly lower in those with AD than in cognitively intact individuals2. This is not to say that those with AD do not feel or report pain, it appears that they may not report of “chronic pain”. The same study found no difference between the AD and control groups with respect to analgesic consumption for acute pain2.
A study looking at pain sensitivity and fMRI demonstrated that pain perception and processing are not diminished in those with AD3. We can safely conclude that an ankle sprain or a pinprick to the tip of a finger is felt the same way in those with AD as in you and I. A meta-analysis demonstrated no significant difference in pain threshold, pain tolerance, or pain intensity ratings between those with AD and healthy controls4.
A German study showed that nursing home residents with AD exhibited significantly less additional pain-associated diagnoses when compared to those with cancer or
Parkinson’s disease5.
I was extremely surprised to realize that to date there are no quality studies investigating the neurophysiology explaining the elimination of persistent pain is individuals with AD. Perhaps by learning how and why some pain is “forgotten about” in those with AD, we may be able to tap into better understanding of patients with persistent pain who have normal cognition. Perhaps investigating AD can help us manage patients in chronic pain states.
References:
- Neumann-Podczaska A et al Analgesic use among nursing homes residents, with and without dementia, in Poland. Clin Interv Aging. 2016 Mar 21;11:335-40.
- Pickering G et al Acute versus chronic pain treatment in Alzheimer’s disease. Eur J Pain. 2006 May;10(4):379-84.
- Cole L et al Pain sensitivity and fMRI pain-related brain activity in Alzheimer’s disease. Brain. 2006 Nov;129(Pt 11):2957-65.
- Stubbs B et al. Is pain sensitivity altered in people with Alzheimer’s disease? A systematic review and meta-analysis of experimental pain research. Exp Gerontol. 2016 Sep;82:30-8.
- Kutschar P1, Lex K2, Osterbrink J2, Lorenzl S2. [Parkinson’s disease, Alzheimer’s disease and oncological diseases in residential geriatric care: Pain frequency and selected healthcare features in comparison]. [Article in German] Schmerz. 2018 Jun
More Articles by Bahram Jam, PT
- Ribs don’t sublux. Ribs don’t “go out”. …so what’s going on?
- A New Paradigm in Manual Therapy: Abandoning Segmental Motion Palpation
- Cupping: A Novel Method of Soft-tissue Release
- Paradigm Shifts: Use of Ice & NSAIDs Post Acute Soft Tissue Injuries (Part 1 of 2)
- Paradigm Shifts: Use of Ice & NSAIDs Post Acute Soft Tissue Injuries (Part 2 of 2)
- Serum Cholesterol and Low Back Pain!
- Fingertip-to-Floor (FTF) Test: Simple, Reliable and Valid
Additional reading by Bahram Jam:
Pain Truth Makes Sense: Working Through Chronic Pain After Trauma
What is pain? Why do people feel it? Where exactly does it come from? Most importantly, how can pain be eliminated or at least reduced? These are questions Dr. Bahram Jam is asked hundreds if not thousands of times every year as people turn to him for help in treating their various pains. Dr. Jam entered the field of Physiotherapy with the goal of helping people overcome and heal from chronic pain.
Interesting topic, i assume old lady was more active since she was less bothered by pain in the neck and knees and her thoughts were elsewhere (the positive in negative situation.) She eliminated barrier that was keeping that pain active and by forgetting pain was there in the first place.. or maybe she had pain but keeps forgetting about it.