Dr John Salmon Pain Medicine Specialist Website
We are a private specialist practice based in Cottesloe Perth W Australia.
We offer the gold standard Interdisciplinary Multimodal Pain Therapy (IMPT) approach.
We specialise in implanted Neuro-modulation Therapy.
Why have I got chronic pain?
Chronic pain affects 20% of the Australian population including 10% of children and adolescents.
At least 8% of the population have their quality of life and capacity to work and be active significantly restricted by pain. It is the leading medical cause of diminished quality of life and economic loss to the community.
The causes and mechanisms of persistent pain are complex and highly individualised. Every person’s nervous system is as different as their external experience and personality.
Persistent pain is frequently initiated by injury, illness or trauma of some kind but it has become apparent that the dominant mechanisms of severe continuous disabling pain are the changes in neural sensitivity that can subsequently develop in the nervous system of susceptible individuals. This phenomenon is termed ‘neural sensitisation’ and may be occurring in both the brain and spinal cord and/or the peripheral nerves. About 10% of all populations in the world are prone to develop central nervous system sensitisation resulting in Chronic Widespread Pain formally known as Fibromyalgia.
This sensitivity of the nervous system explains why persistent pain can become more severe, widespread and disabling over time, frequently unrelated to peripheral pathology change .
In fact there is a less than 50% correspondence between the extent of degenerative change pathology and the severity of pain and disability affecting the individual. Half the population with severe joint including spinal arthritic change have relatively minimal symptoms. It is therefore not surprising that orthopaedic and surgical fixes of peripheral pathology don’t always work.
The good news is that this statistic means that you dont have to be a prisoner of severe disabling pain because you have severe degenerative pathology; your neural sensitivity mechanism can be modulated.
Another important aspect of the chronic pain condition is the strong interaction with mood and also stress related to an individual’s social and work environment. The experience of pain is not just a particular sensation, it is a strongly emotional experience that most frequently sets in motion a vicious circle of fear, anxiety and depression that then exacerbates the condition.
It is important to understand these basic facts about chronic pain because the key to successful management is treatment that addresses the fundamental mechanisms of persistent pain and related suffering and disability.
How to treat chronic pain ? What science tells us:
There are therefore two key treatment issues to address:
1. The biological mechanisms- in particular the neural sensitisation but also the inflammatory and biomechanical components.
2. The ‘psychosocial’ mechanisms-the vicious circle of fear, anxiety and depression resulting in avoidance of activity and participation with life and increasing negative thinking about the future.
In this clinic we offer the gold standard and scientifically supported ‘interdisciplinary multimodal pain therapy’(IMPT) approach. We are able to do this because we make the effort to provide individualised treatment from a team of allied health therapists who network and collaborate together.
These therapists comprise specialised physiotherapy, occupational therapy and psychotherapy.
Your care starts with a comprehensive medical assessment and review of your condition which typically takes 40 to 60 minutes.
This review will cover the detailed history of the development of your pain condition and how it has affected your life and interactions with your work and home environment and any other medical conditions and history that you have and also your family medical history. Any relevant physical pathology is comprehensively examined and assessed.
Most frequently you will have had a considerable amount of treatment that hasn’t helped much or might even have made you worse. You may have become dependent on strong opiate analgesics with diminishing benefits over time. You may have given up hope of resuming a reasonable level of function and quality of life.
Following this initial medical assessment you will receive a 2 to 4 page medical report describing your condition and situation in detail and this report is also sent to your referring and treating doctors and to any allied health therapists who will be contributing to your treatment. This report will outline the treatment plan.
It is most important that everyone is on the same page !
The medical treatment component starts with review and optimisation of your analgesic and psychotropic medication. Particular attention is paid to systematically identifying which medication is contributing a significant benefit and adjusting the dose to avoid significant side-effects and to cease any other medications that are not in fact helping . Fortunately we now have some strong analgesics that are relatively non-addictive.
Medications that can reduce neural sensitisation pain mechanisms are of significant value and there are a range of these medications whose efficacy for an individual needs to be carefully assessed and the dosage adjusted for maximum benefit avoiding side-effects.
Treating the physical, emotional and functional components of the chronic pain condition
The first step is referral to a chronic pain specialised physiotherapist in our network.
The physiotherapist will typically spend 40 to 60 minutes with you because assessing your particular pattern of interactive neural sensitivity and biomechanical pain mechanisms is frequently complex and challenging and then there is the task of devising a specific home-based treatment program that will address these mechanisms.
This input does cost a bit more than a standard physiotherapy treatment but it is absolutely necessary and of great value to you if you participate adequately!
We are fortunate in Perth to have some of the world’s leading schools of physiotherapy.
You next step will frequently be referral to LifeWorks occupational therapy who are a team of specialised pain management trained occupational therapists whose role is to review in depth the impact of your persistent pain and disability on your life as a whole both at home and related to work or work goals and study.
They can help you a great deal with modification of the way you go about being active and setting carefully graduated and individualised activity goals.
The concept and strategy of activity pacing is absolutely central to achieving a sustainable return to function and quality of life.
All your other medical and physical and psychological treatment inputs will work much better if you have the necessary help to put basic activity management strategies in place-and keep on applying them. LifeWorks also offer telephone and Skype follow-up consultations and home visits if appropriate. Partial funding for this treatment is available through Medicare mental health funding.
You will be amazed how helpful this is!
Pain is in the brain as well as the body
If it is apparent that your mood has become significantly anxious and depressed, and you may have a history of previous significant mood disturbance, and the extent of this aspect is severely interfering with your treatment and return to function then it will be of great value to you to have some further input from a psychotherapist specialising in cognitive behavioural (including mindfulness) based therapies.
Post-traumatic stress disorder (PTSD) is now recognised to be significantly more prevalent after trauma than previously thought and is a recognised risk factor for exacerbation and prolongation of chronic pain after motor vehicle accidents and other trauma . It can respond well to appropriate CBT-based treatment input.
The adversarial environment and inappropriate biomedical fixation of the workers compensation and motor vehicle insurance systems in Western Australia frequently add anger, confusion and distrust to the mix.
The result is a significantly increased generation of chronic pain syndromes , disability and medication and substance dependence .This requires an adequate intensive interdisciplinary (IMPT) treatment approach to unravel.
Because of this negative adversarial environment ramping up neural sensitivity, surgical treatments for work and motor vehicule injuries carry a fourfold risk of poor outcomes.
We coordinate with a network of specialised psychotherapists around Perth.
Pain management interventional treatment
The initial treatment strategy is to optimise self-management via this collaborative treatment approach and also rationalised medication and if you are established on an adequately improving trajectory that maybe all the treatment you require.
However if it is clear that high levels of neural sensitivity and/or inflammatory or biomechanical pain mechanisms are interfering significantly with recovery of function then the second stage of treatment is to look at the option of pain management procedures.
Injection and radiofrequency treatment
Most commonly this will consist of carefully targeted x-ray guided injections of anaesthetic and steroid around sensitised pain generating nerves and joints and also neuro- modulation of neural sensitivity mechanisms by pulsed radiofrequency application to nerve root ganglia and sometimes peripheral nerves. On occasion thermal radiofrequency numbing of the nerves to the facet joints can be of benefit.
In many patients these interventions have sufficiently sustained benefit that physiotherapy supervised exercising and graduated reactivation can resume steady progress- a vicious circle is broken.
However in a relatively small minority these injection and radiofrequency therapies have minimal or very temporary benefits only and are then not worth pursuing further.
The risks from these procedures should be very low, so low that they are difficult to quantify- certainly less than the risks associated with say driving a car. However they are not risk-free and that needs to be recognised.
This clinic has performed over 8000 cervical and 20,000 lumbar epidural injection and nerve root sleeve injection (trans-foramenal epidural) and pulsed radiofrequency treatments over the last 28 years with no significant complications.
Implanted neuromodulation therapy
For the small proportion of patients who have severe intractable neuropathic or neural sensitisation pain mechanisms that impede all conservative treatment approaches we have a ‘big gun’ treatment in the form of implanted neuromodulation therapy.
Implanted neuromodulation has a 50 year history in the management of persistent pain and the safety of lifelong electrical stimulation of the spinal cord and peripheral nerves is in now well-established.
The good news is that advances in technology over the last 10 years have markedly improved the efficacy of this treatment for a wider range of chronic neuropathic pain conditions including chronic headache and widespread pain syndromes.
In particular high-frequency at 10 kHz spinal cord stimulation (supplied by the company Nevro Inc) and burst waveform spinal cord stimulation (supplied by the company Abbott) is capable of providing 60 to 70% sustained pain reduction in about 80% of patients with intractable neuropathic pain.
There is high level (randomised controlled trial) scientific evidence supporting the efficacy and safety of this treatment. It is also cost-effective because a high proportion of patients receiving this treatment become capable of returning to work/study and largely ceasing medication and other treatment input. It should be much more widely available but lack of adequately skilled specialists and the significant cost to the health system of the device remains a barrier.
Private hospital health insurance in Australia fully covers the cost of these devices and this clinic is one of the most experienced providers of this treatment in Australia.
We have placed over 1000 stimulator implants over the last 28 years and the outcomes from this treatment have been regularly assessed and presented at national and international conferences and published in medical journals. We can supply you with this outcome data.
Additional reassurance is that you have a minimally invasive trial of this therapy before proceeding to implant and this therapy is fully reversible leaving your anatomy unchanged. We’ve had no serious complications from neuromodulation implant therapy.
We are therefore very confident about offering this treatment to selected patients.
We are also involved in the research and clinical evaluation of the next generation of implanted neuromodulation therapy which will be considerably less invasive and less costly and potentially even more applicable to a wider range of patients.
You may continue to be amazed!
Documenting outcomes is key to the evolution of effective therapy
We are dedicated to the effective application of evidence-based medicine to produce the best possible outcomes for chronic pain sufferers. To this end we participate with the nationwide electronic pain patient outcome collaboration (ePPOC) which systematically collects arm’s-length outcome data from participating pain centres across Australia (over 70 at present). The statistical outcomes in several domains is collated at the University of Wollongong who benchmark outcomes and rankings are tabled. Our clinic currently reaches all the benchmarks and exceeds the benchmark for pain reduction by more than 90% which puts us in the top six rankings of pain clinics in Australia.
If you need further confirmation of the scientific support for the biopsychosocial model and resultant IMPT treatment approach you should look on the W.A. Health and International Association for the Study of Pain (IASP) websites .
Beware the snake oil salesman in the medical and allied health professions !
Unfortunately quick fixes for chronic pain remain generally unavailable -if there were easy fixes we wouldn’t have such a massive problem would we ? Recognition of the individual variation and complexity of the neural mechanisms and psychosocial influences that result in the chronic pain condition in an individual will likely dictate that there will never be a simple quick fix for most patients with severe disabling pain.
It is therefore important to beware of the many snake oil salesmen in the commercial world of medicine and health care who will promote their pet treatment intervention to the exclusion of all else and which typically has little or no evidence base, is costly and depends on your repeated participation for an indefinite period.
These therapists are income rather than outcome driven !
We want to liberate you from costly ongoing treatment .
Our goal is to render you self managing, sustainably active, functional and mood positive and thereby you will become largely independent of the requirement for medication and further treatment interventions .