Thomas Smith, MD, Professor of Palliative Medicine & Oncology at Johns Hopkins Kimmel Cancer Center talks about scrambler therapy to reduce pain.
Interview conducted by Ivanhoe Broadcast News in 2024.
By palliative medicine, you mean that for people who are on their way out, you’re making them feel better on that journey?
Smith: Palliative medicine can be applied at any point on a person’s illness trajectory. We treat curable patients. It’s designed to have a team of doctors, nurses, social workers, psychologists, and chaplains to help maintain your quality of life. Reduce pain, reduce symptoms, reduce distress. Some studies even show people who have palliative care, alongside their usual care, live substantially longer.
You touched on something there on the caregiver’s trajectory during the illness. It eases them too because what I’m getting at is there’s nothing more painful than somebody listening or watching someone else in pain. What does that pain do to the patient’s overall medical condition? Does it aggravate it?
Smith: Pain makes everything worse. It makes every other symptom worse. If it’s chronic pain, it’s always there right in front of you, coloring your worldview. You get up with pain, you go to bed with pain. You don’t eat as well, you don’t move. You’re more likely to get pneumonia, more likely to get a blood clot in your legs. It destroys people’s quality of life, sometimes unnecessarily.
Hearing someone shriek, or scream, or moan, or anything, what I’m trying to do is to paint a picture for people watching this. The pain is not only painful, but it’s also very derogatory to the healing process.
Smith: Chronic pain, whether it’s cancer pain or noncancer pain, is very much to the detriment of the person who has it. One of our first studies we did was with an implantable drug delivery system that gives pain medicines right into the spinal fluid. This showed that people who got their pain relieved not only had much better pain control, but they lived three months longer than those who didn’t. Pain kills in some way: I think it kills because people stop going to synagogue. They stop going to Little League games, they stop going to the dinner table, they don’t feel like eating, and their system just goes down like that. They’ll get pneumonia and other infections or get blood clots and pass away too soon.
Many people die from pneumonia and lack of movement when they’re hospitalized, right?
Smith: Pneumonia used to be called the old man’s friend, sometimes it still is. Sometimes people get into the hospital even when they have almost no chance of surviving and end up spending their last days on a ventilator which is not what most people want to do. Most people, if they must die, want to die at home surrounded by the people they love, the pets they love, a familiar environment, and good memories.
What does the pain do directly in the brain? Because you’re talking about them communicating with their family members. When you are hurt, you don’t care what anybody is saying. What is it doing to the signals in the brain?
Smith: Chronic pain is not doing anyone any good. Your poor brain is getting constantly barraged by pain signals coming from your foot, from your leg, from your hips — maybe it’s a broken bone, or maybe it’s a metastasis. You’ve got these chronic pain signals going up to your spinal cord, to your brain, to the pain centers on either side and that redistributes the blood flow. These areas get too active. Normally, the brain should work to suppress that chronic pain. Sometimes, however, it does the wrong thing, and it ramps it up. Neurologists call this wind-up. We see this a lot when somebody has an injury that shouldn’t be too terrible, but gets worse and worse and worse over days, weeks, and months and may last for years, something called complex regional pain syndrome.
Because the brain is overfiring and it’s gorging with blood?
Smith: It’s not that the brain is over-gorging with blood, it’s that the blood in the brain is being directed towards the pain centers. They’re hyperactive. The inhibitory centers which are out in the front of the brain aren’t getting their appropriate blood supply. They’re not doing their job inhibiting those pain impulses. That’s just one of the mechanisms by which chronic pain affects the brain.
What is Scrambler therapy?
Smith: With chronic pain, your spinal cord and brain are being barraged by this influx of signals from pain nerves, particularly your C fibers. Those are the ones that carry the worst type of pain signals. What the inventor did was make a machine that captures those nerves. Let’s say you put an EKG electrode above and below the pain, and asend this artificial nerves “non-pain information” along the normal pathwayss. It captures all those nerve endings and sends something up the spinal cord and to the brain that looks the same size, shape, same waveform as the pain signal but isn’t pain, it doesn’t hurt. It replaces or scrambles the pain signal going up to the brain; do that often enough, and if you’re a person who’s responsive to scrambler therapy the brain will reset, and that chronic pain can go away for days, weeks, or months.
Provide us the explanation of the connection between where you place those leads and how the scrambler knows that’s where the pain is because that’s where the leads are.
Smith: If I’m having chronic pain in my hand, say I had an injury to one of the little bones. Instead of suppressing the pain, the pain continues to get worse and worse. We can put an electrode above the pain here and its matching electrode above the pain there on the nerve supply that goes to the hand. Then it captures those nerve endings that are sending the same signal as these nerve endings. Down here are the ones that are sending the pain signal. It’s sending this signal, non-pain.
Everybody visualizes something different. But when you tell me that I’m thinking about these signals inside or just scrambling themselves and waves or whatever, what is it? If you could look inside somebody’s arm, for example, what would you say?
Smith: If you could look inside these nerves that you’re capturing, you’d see that it’s capturing the nerve endings and using those nerve endings to send a nerve signal up the main nerves to the spinal cord just like the pain signal is doing. It hits the spinal cord and connects to a second nerve, that second nerve takes it up to a third nerve in the brain and it can replace that pain signal and quiet this area down.
When you put the leads on somebody, you said it’s like thousands of electric ants just nibbling at you, that goes through it dulls the pain in the brain. How long of a process is it and how long does it last?
Smith: Well, when you have the electrodes on your arm, to me it feels like I’m being bitten by a little tiny electric ants. It’s constantly shifting. That’s one of the things that makes this unique — it’s a constantly shifting signal, so the brain can’t get used to it. Each treatment takes about 30 to 45 minutes a day. Start with one or two treatments to see if the person is going to get a response and you may need up to 10 and sometimes 12 for a difficult pain.
After those 10 treatments, what then happens to the original pain signals? Are they so scrambled they don’t go back to be in real legs or what?
Smith: It’s reset the brain so that it can now ignore the pain signals coming from there. You’re probably familiar with a TENS unit which you can buy at Target. It doesn’t work very well. The other part is as soon as you turn the box off or take the electrodes off, all the effect is gone. That works on a different type of nerve, the A fibers. Scrambler works on the C nerves and it can repair the damage done to the pain system. The brain is a whole lot more plastic than we give it credit for. I was taught in medical school a long time ago that once the brain is damaged, it’s damaged, or once the brain is set in something, it’s set. It turns out that’s not true. The brain can repair itself a lot better than we thought.
I’m trying to describe how the brain is once it’s got the idea not to send the pain signals anymore. You’re in essence, tricking it or fooling it. Is that accurate?
Smith: We’re resetting the brain. I wouldn’t call it tricking. I would call it resetting because normally your brain should inhibit all those chronic pain signals so that you can live with them. Pain is one of our most important reflexes. You must feel pain if you get bitten by a saber tooth Tiger. At the same time, you can’t be paralyzed by it. As soon as you have pain impulses going up, you’ve got inhibitory impulses right next to it that are dampening it down so that you can run at least faster than your neighbor.
Let’s say somebody, like Kelly, that we’re going to interview this afternoon, we’re going to shoot her treatment. How long have you been treating her? Specifically, what for and how is she responding?
Smith: We met Kelly in the intensive care unit. She was very sick, she had a whole host of medical illnesses, and she had a biopsy of a nerve right down here trying to figure out what was why her nerves didn’t work, and almost immediately, she got something called complex regional pain syndrome where the whole body that’s been injured, overreacts. She got purplish-red discoloration. The leg swelled to twice its size. It became extraordinarily painful one couldn’t even touch it without her screaming in pain. That continued for weeks and weeks, and it never got any better and it crept up the leg to almost her knees.
Was it from the biopsy doctor?
Smith: It wasn’t from the biopsy. It was from her body’s response to the biopsy. Some of us have pain systems that I think are a little bit too tightly wound, some people when they have a physical insult, the whole body in that area starts to go haywire. It swells, and it turns purplish red. It gets hypersensitive to pain. Leave it long enough and you’ll start to lose bone in that area. Because you can’t move it because it hurts too much. We saw her in the ICU and put electrodes above where the pain was trying to catch the same nerves that were coming from her foot. With about 10 to 15 treatments over six months, it completely resolved. She still has a little bit of hypersensitivity technics. She still has a little bit of hypersensitivity on the lateral side of the foot, and when that starts to bother her, she’ll send me a chart message and I’ll arrange for her to come in for two or three treatments, and that’ll fix it for another three months or six months, or sometimes even longer.
She’s much better now, what other medical problems were diagnosed when she was in the ICU?
Smith: She’s had several episodes where her heart beat too fast to sustain life. Her small intestine doesn’t work well, it doesn’t push things through like it should, she has a cardiac pacemaker and defibrillator in, and a couple of other things.
The pacemaker is inside an electrical device, how does this affect that?
Smith: It doesn’t affect it at all. The electrodes are a yard away from the pacemaker and the scrambler signals never get close to the pacemaker.
That doesn’t have to go fast to get up here?
Smith: No, it follows the normal nerve signal in your spinal cord. Plus, she was in the ICU, she was on a monitor. We figured we had as safe a setting as we were ever going to have, and she’d already been failed by most of the other things we try to do with complex regional pain syndrome. They didn’t work.
How many times has that happened, and how long of a process is that?
Smith: She comes in for two or three daily treatments every few months. Each one takes about 45 minutes. We know now exactly where to put the electrodes to capture those damaged nerves, because where they took the piece of nerve out, beyond it is still damaged and it’s still sending pain signals. It hasn’t healed the nerve, it doesn’t heal the nerve, but what it does is it resets the brain so that its brain can successfully ignore those chronic pain signals because we’ve replaced them with something that does not cause pain.
What diagnostic equipment is used in conjunction with RCT and MRI, and afterward, what is her overall percentage of how much better she is at healing the other parts of her body that are having issues?
Smith: There are no good methods to diagnose pain. The first person who invents a true painometer will sell a million of them on the first day. Pain is what the patient says it is, and it’s an unpleasant experience. Her pain was localized to her right leg. It was so bad she couldn’t walk; she couldn’t wear shoes; she was on crutches when she got out of the hospital. Now she’s wearing normal shoes, she’s being a normal mom, she can do pretty much anything that she wants to. She just must come back in for tune-ups occasionally.
What’s your level of pain on a scale of one to 10? He gives them a random number and writes it down. I don’t know what happens after that. My point is, do you ever foresee a day this is a critical issue with patients where this is going to become part of the pre-treatment, if you will?
Smith: Starting back in 2000, we began to emphasize pain as the fifth vital sign after your breathing rate, your blood pressure, and your pulse, pain was the fifth one. That didn’t seem to change anything. Unless you have a way to fix it- unless you have a good way to fix it, you can’t do much about it. Plus, some people will be in terrible chronic pain, and they’ll look completely normal. Their pulse rate will be normal, their eyes won’t be dilated or constricted, they’ve adapted to it, but they’re in terrible chronic pain. Other people appear to have a much lower pain threshold and for them, what might be a minor injury to someone, could be nine out of 10, or 10 as the worst possible pain.
It is an esoteric thing because even when they’re saying it gives them a number. Can you describe the brain scrambler in one nice definition for us?
Smith: We follow the pain scores. We follow the pain score, particularly, right before we start treatment. If it’s seven on the first day, we hope to make it go down to three after 30 or 45 minutes. Then the next day, it’ll probably come back up to five, and then we hope to make it go down to one or two. Eventually, over the space of five to 10 treatments, try to get it as close to zero as possible, because if you can get it to zero for 24 hours, chances it’s going to stay close to zero for weeks or months.
For the person watching this and wherever they happen to be, in Los Angeles, Cleveland, are these brain scramblers already in medical facilities?
Smith: There’s an increasing number of scrambler therapy units across the country and in the military. Unfortunately, Medicare set the reimbursement for it at such a low rate that there’s no way you can even afford to buy the machine. We’re hoping at some point that those changes. I could take the same person and walk them over to the Blaustein Pain Center and have one of my colleagues put in a fancy peripheral nerve stimulator made by a big company, and the reimbursement for that, the surgeon’s fee would be 2,500 dollars. When Medicare looked at this, they said you’ve shown us data from 2,600 people without a single serious side effect, none. You’re not sticking needles into people; you’re not injecting drugs into people. To us, it looks like a fancy TENS unit that you could buy in the drugstore, except it’s much bigger. We’ll set the reimbursement at 32 dollars for 30 minutes, which is the same as a physical therapy technician putting on a TENS unit. That must change. Right now, there’s no economic model that makes this work, so people who do it are either doing it because they love doing it like me, we’re billing for doctor visits and we’re at the same time educating about pain, teaching mindfulness, teaching meditation, doing everything possible in drug management to help that person even while we’re giving the Scrambler therapy.
What does is Scrambler? Describe what it is and what it’s doing.
Smith: The scrambler therapy unit has five separate channels or sets of electrodes. Each one is acting as an artificial nerve or neuron. If you put the two paired EKG electrodes 8-10” apart, it’s going to capture all the nerve endings in the skin and use your native nerve network to send that up to the spinal cord, just like a pain signal. The spinal cord will carry it up to the opposite side of the brain, just like a pain signal, but it’s not perceived as pain. It may feel like being bitten by tiny electric ants, but it’s not pain, and it can replace that pain signal and, eventually, reset your brain’s pain mechanism and inhibitory mechanisms such that you don’t feel that chronic pain at all or nearly as bad.
END OF INTERVIEW
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