Cuban Medical Research
PAIN CLINIC: The Impact of Traditional and Natural Medicine

INTRODUCTION

Humankind has always fought against pain and its bio-psychosocial effect on human beings. It is this symptom that makes many patients seek medical help.  Its physical and pathological features as well as its quantification are, however, very difficult to determine.   Sir Thomas Lewis said “…We know pain by experience, and we describe it by comparison.  Pain implies damage to the body, be it physical or psychological, and the doctor must treat it whether the cause is curable or not.”

Pain relief has always been a main goal of physicians.  To do so, one must understand what pain means for the person who is suffering.  A dreadful, alarming and unpleasant experience, pain is a neuro-physiological and neuro-chemical and biochemical occurrence, associated with the stimuli that cause tissue damage.   At times, organic damage does not even occur, but there are painful feelings and perception of abnormal circumstances.  It is a subjective, objective and behavioral response, with unpleasant manifestations of fear, anxiety, or escape, provoked by nociceptive stimuli. (2)

Pain is a frequent and distressing symptom that still lacks a strict definition and a complete explanation in terms of its physiological and biochemical mechanisms.  It has been defined in a very practical and useful way as a triad consisting of nociceptive stimulation with affective and interpretative aspects.  The degree of sharp pain can thus be explained by means of the contributions of these three components.  Pain is almost always a temporary phenomenon, but, occasionally, it persists for weeks or months and then becomes a symptom that is described as chronic pain. Patients suffering from benign chronic pain resort to numerous doctors and hospitals, and are treated with several combinations of analgesics, psycho-stimulants, as well as other drugs administered through various means (3,4,5).

Studies conducted by international entities show that one third of the population in industrialized countries suffer from some type of chronic pain.   Fifty to seventy percent are partially or completely handicapped for days, weeks or months, while the other 30% are permanently disabled.

Lack of understanding of the physical and pathological mechanisms involved in pain syndromes, and the wrong prescription and application of therapeutic methods expose these patients to medical complications which include pharmacological toxicity, dependence on narcotics, and useless surgery which is at times mutilating. (5) The very nature of pain demands a multidisciplinary, multi-modal approach that has resulted in a change in the philosophy of super specialization, moving towards more integrated and interdisciplinary concepts and the creation of pain clinics. (4).

In the last few years, a new trend has emerged in medical science throughout Latin America and other regions promoting less invasive methods, and the use of helpful natural and biological elements, which have been scientifically validated through research and have proved very effective on patients.

The first treatment of pain by means of nerve blocks was conducted in Cuba in 1950, in the Service of Anesthesiology of the former Quinta de Dependientes del Comercio de la Habana (now known as the 10th of October Clinical-Surgical Teaching Hospital).  Since then, there has been a gradual increase of interaction with other specialties, non-invasive methods have been introduced(6,7,8,9) and teaching of these developed, resulting in the creation of the Pain Clinic.

Starting in the 1980’s, the Clinic at the 10th of October Hospital has incorporated several specialties: Anesthesiology, Surgery, Psychology, Internal Medicine, Oncology, Orthopedics, Physiotherapy, Nursing, etc. (4,5), in the study and treatment of patients who suffer from pain and other afflictions.   Methods of Traditional and Natural (also known as Biological, Alternative, Reflex therapeutic) Medicine are integrated with conventional medicine in our system.  These methods include acupuncture, electro-acupuncture, laser-puncture, facial-cybernetic therapy,  moxibustion, psychotherapy, relaxation, auriculotherapy, musical therapy, massage, hypnosis, trans-epidermal neuro-stimulation (T.E.N.S.), as well as nerve and surgical blocks (10, 11, 12).  Both teaching and research have been developed to support this project.

These methods are straightforward, and do not require much equipment.   Techniques are easily assimilated, and they are effective for a large number of illnesses as a result of their analgesic, homeostatic, immunizing and sedative effects.   If properly applied, these therapies will not cause further complications, nor side effects.  They save medications, personnel and equipment, and shorten the patient’s rehabilitation period.  They can also be applied in less-than-ideal conditions. (10, 11, 12).

Modern theories on the action mechanisms of these methods, such as the Melzack and Wall Theory and the Theory of Neuro-transmitters, argue that these methods act through neuro-physiological mechanisms.  The Immunology and Ionic Theories, among others, explain their actions as well. 

The present study incorporates a ten-year experience at the Pain Clinic with the above-mentioned methods aiming at pain relief.   The clinic has contributed to making correct and optimum use of a variety of therapeutic methods in the pathologies under study, and has also lowered the cost of treatment (since no drugs are needed), and patients rapidly return to their social and work environment.

GENERAL OBJECTIVES

Assess the results achieved in the last ten years (1989-1998) in the treatment of patients at the Pain Clinic of the 10th of October Clinical-Surgical Teaching Hospital.

SPECIFIC OBJECTIVES

MATERIALS AND METHOD

189,832 medical records of patients with pain were surveyed.  These patients came to the Pain Clinic looking for treatment between January 1989 and December 1998.    All the techniques used in the last ten years were recorded:  electro-acupuncture, acupuncture, laser, facial-cybernetic therapy, TENS, moxibustion, psychotherapy, relaxation, auriculotherapy, massage, hypnosis, magnetic therapy, green medicine, music therapy and anesthetic blocks.

The survey of clinical records yielded general data for all the patients, including age, sex, race, and personal history of pathologies.  For each kind of therapy, the record included the diagnosis, number of sessions, degree of pain, possible adverse effects, and, whenever necessary, change of therapy.   No analgesic or anti-inflammatory medications were used during treatment with natural and traditional methods.

Variables of response to treatment were considered following the visual analogical pain scale between 0 and 5, where 0 stands for a patient showing good treatment response, and 5 stands for severe pain with unsatisfactory therapeutic response. When the figure moves down 1 to 2 values on the initial scale, results are considered satisfactory.  The method was considered unsatisfactory when the values remained the same or moved up in comparison with the initial scale.

The information was gathered from the Quest-Tree Database System, in which all  medical records of this service were registered.   Proportions were made to determine the number of sessions per treatment, the number of patients requiring another therapeutic method, and those with adverse effects.   The necessary tables and graphics were prepared using Harvard Graph 3.

ANALYSIS AND DISCUSSION OF RESULTS

A study was conducted at the Pain Clinic of the 10th of October Clinical-Surgical Teaching Hospital between January 1989 and December 1998.  The research universe for this work was the total number of patients with painful and non-painful pathologies who received treatment.

A total number of 189,832 patients were included in the study; 186,035 (98%) received treatment with Natural and Traditional Medicine, and the remaining 3,797 (2%) were treated with conventional medicine, mainly nerve blocks.

Women visited the Clinic more often than men: 134,268 patients (70.73%).  White patients were predominant, 136,869 (72 %); and the most frequent age group ranged between 45 and 65 years, 102,149 (53.81%).  Our findings coincide with those of other authors (8,14): women visit doctors more frequently than men. Likewise, the ages coincide with the most active stages in the social life of our population, whose social composition is similar to what we found in the study (15).

Among the patients, we found 107,066 (56.40%) with pre-existing conditions that included high blood pressure, 52,089 (27.44%); bronchial asthma, 20,843 (10.98%); and diabetes mellitus 15,907 (8.38%).  These are the pathologies most frequently seen during doctor visits. (16).  The largest number of therapeutic methods applied included electro-acupuncture in 65,359 cases (34.4%); acupuncture, 61,600 (32.5%); and laser 38 156 (20, 1 %).   Blocks (an elective treatment) were administered only to 3,797 patients (2.0%) who suffered from terminal cancer and reflex sympathetic dystrophies  (13,17). (Table 1).   A total of 177,493 patients (93.5%) were treated for painful illnesses, the most frequent ones being lumbosciatalgia, sacrolumbalgia and cervicobrachialgia. 12,339 patients (6.5%) had non-painful pathologies, including muscle atrophy, bronchial asthma and high blood pressure. 

Table1, Distribution by methods of treatment

N = 189,832

METHOD	TOTAL	PERCENT
Electro-acupuncture	65 359	34.43
Acupuncture	61 600	32.45
Laser	38 156	20.1
F.AC.I.	8 542	4.5
T.E.N.S.	4 176	2.2
Moxibustion	3 990	2.1
Nerve Blocks	3 796	2.0
Massage	1 898	1.0
Auriculotherapy	1 708	0.9
Magnetotherapy	379	0.2
Homeopuncture	228	0.12

The number of patients and treatments using a variety of Traditional and Natural Medicine methods totaled 275,492, showing an increase in comparison with those described using nerve blocks and other conventional methods (Figure 1).  The average of natural and traditional treatments per patient reached 9.7, with a 90.6% effectiveness.  This data coincides with that reported by Cuban and international authors (8,14,18).  (Table 2).

Figure 1, Treatment conducted

Table 2

	N.T.M.	BLOCKS
Total Number of Patients	186 035	3 797
Treatment/Patient Average	9.7	5,2
Effectiveness	90.6 %	92 %
Complications	0	5

The techniques most used required a small number of the sessions prescribed to improve the patient’s condition.   Electro-acupuncture needed an average of 8.3 sessions, while acupuncture and laser required 9.01 and 9.16 sessions respectively.   The number of block sessions was 5.2 per patient.  The total average of treatments was 9.5.

169,330 patients (89.2%) showed satisfactory results.  75,933 (40.0%) needed 5 sessions, while 93,397 (49.2%) required 10 sessions.

20,502 patients (10.8%) did not indicate satisfactory pain relief with the initial treatment, and required a change of therapy to electro-acupuncture 6,075 (3.2%), laser-puncture,  5,315 (2.8%), and acupuncture 3,037 (1.6%). The remaining patients were treated with other Natural and Traditional Medicine therapies as a new therapeutic option 6,075 (3.2%).   Complications were reported in five patients who received blocks:  3 patients with high blood pressure and 2 patients with perforated dura mater.

None of the patients treated with Traditional and Natural Medicine showed any adverse reactions, due to the innocuous method used or to the fact that no drugs were prescribed (3.10).   Of the patients who visited the Pain Clinic between 1989 and 1998, 186,035 were treated with Traditional and Natural Medicine, who therefore did not require medication of any sort.   Had these patients not been treated with these methods, but with blocks (the conventional treatment used in our clinic), the additional cost would have been close to 1.5 million pesos (Table 3).   In addition, when natural methods are used on ambulatory patients, they can go to work, which makes the social cost much lower than treatment with blocks.   Considering that specialists generally prescribe a medical leave of absence for at least one month for patients requiring blocks, and that the average salary of those receiving treatment with natural methods in the period under study (143,152 patients) was 120 pesos a month, means that the government (employer) saved close to 9 million pesos in subsidies. Furthermore neither the patients nor their families were monetarily affected, as wages were not reduced by the need to take long sick leaves (which can be as much as a 50% reduction, depending on the time taken).   In other words, from the social point of view, there were some 17 million pesos in savings, substantiating the conclusion that Traditional and Natural Medicine methods are preferable from both medical and economic standpoint.

Table 3, Compared costs of n.t.m. & nerve blocks

	UNITS	BLOCKS	N.T.M. METHODS
Average cost of one treatment	PESOS	5.65	2.25
Average number of treatments by patient	ONE	5.2	9.7
Total cost of treatments by patient	PESOS	29.38	21.82
Total cost (186 035 patients)	THOUSANDS OF PESOS	5 165.7	4 059.3
Additional cost of blocks	THOUSANDS OF PESOS	1 406.4	----------

Along with these procedures, these patients have been treated with group music therapy (52,809) and psychological counseling (10,332).   500 of these treatments consisted of hypnosis or hypno-relaxation, conducted with techniques designed in the Pain Clinic based on international experiences (19,20,21).   Successful results were attained in pain relief, reduced anxiety, depression and sleep disorders associated with the cause of pain, and in creating resources to deal with it.    

119 treatments with green medicine were applied to patients with intestinal parasites, resulting in outstanding improvement (22).

In the ten years under study, 290,634 treatments were applied, with an average of 9.5 per patient and an overall 91.4% success rate. (Figure 2).

Figure 2, The Pain Clinic:  ten years of experience

TREATED PATIENTS	189 832
TOTAL NUMBER OF TREATMENTS	290 634
TREATMENT / PATIENT AVERAGE	9.5
EFFECTIVENESS	91.4 %
SAVINGS FOR NON USE OF DRUGS	$ 1 406 400.00
CONTRIBUTION IN HARD CURRENCY	$ 40 000 USD

The Pain Clinic conducted 224 undergraduate and postgraduate courses, rotations, trainings and master courses.   The Courses for National Traditional and Natural Medicine Facilitators were very important, as they initiated the training process in the National Health System with 20,000 specialists from all the provinces who later passed their knowledge on to others. Another landmark was the beginning and development of the first and second programs for the Masters Degree Course in Traditional and Natural Medicine, which have furnished health professionals with a profound mastery of research methods, broad scientific background and advanced knowledge, which they also carried to the rest of the country (Graph 3).

The Clinic conducted lectures, seminars, workshops, courses, and national and international congresses.    The XIV World Congress of Traditional and Natural Medicine was held at the International Conference Center, while the Pain Clinic hosted the pre-congress courses.   Both the Congress and the courses were attended by many experienced Cuban and international scientists.

Figure 3

TEACHING REPRODUCTION OF HUMAN RESOURCES More than 20 000 National facilitators  More than  500 Masters Degrees in training for N.T.M.

CONCLUSIONS

The Pain Clinic experience has resulted in:

REFERENCES

This article is based on a presentation at BIONAT 2000, First National Congress of the Cuban Society of Bioenergetic and Naturalist Medicine, Havana.

Authors: