Comparable Pain Reduction Research Articles

Combined Ultrasound and Fluoroscopy versus Ultrasound versus Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain: A Retrospective Comparative Study.

Background and Objectives: This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods: A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results: In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups (p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions: When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.

Exploring medicinal use of low-THC cannabis products - Comparing experienced effects and side-effects between CBD-oil-only users to users of high-THC cannabis products

Background Low-THC cannabis products have become popular worldwide and are used as self-treatment for a variety of medical conditions despite limited high-quality evidence on efficacy or long-term side-effects. Method: We compare the experiences of CBD-oil-only users to that of users, who indicated use of cannabis products conventionally higher in THC (high-THC cannabis) with respect to number of symptoms relieved, overall perceived effect on symptoms, effect on pain level and sleep duration, and perceived side-effects. A self-selected convenience sample of Danish cannabis users were recruited to an anonymous online survey. Inclusion criteria were 18 years or older and use of cannabis as medicine (CaM) (prescribed or non-prescribed). Results The final sample included 2.642 users of CaM, of which 992 were CBD-oil-only users and 1650 used high-THC products. Compared to respondents who used high-THC cannabis, CBD-oil-only users reported fewer symptoms relieved by cannabis, a slightly lower overall symptom reduction, as well as comparable pain reduction and sleep improvement. CBD-oil-only users reported fewer side-effects and were more likely to report no side-effects of cannabis. Conclusion: CBD-oils may produce less intense effects compared to high-THC cannabis products, while also producing fewer side-effects. Regulation of the legal low-THC cannabis market is needed.

Arthroscopic Decompression of Calcific Tendinitis of the Shoulder and Repair of Residual Rotator Cuff Defect

Background: Calcific tendinitis is a common source of shoulder pain and represents pathologic deposition of calcium hydroxyapatite within rotator cuff tendon tissue, most commonly the supraspinatus tendon. Indications: Arthroscopic decompression of calcific tendinitis with possible rotator cuff repair is indicated in patients with persistent, debilitating symptoms of pain and/or dysfunction who are recalcitrant to nonoperative treatments, including corticosteroid administration, ultrasound-guided needle barbotage, and/or extracorporeal shockwave therapy. Technique Description: With the patient in a beach chair position, a standard diagnostic shoulder arthroscopy is performed to evaluate for concomitant pathologies. Within the subacromial space, a thorough bursectomy is performed and the area of calcium deposition is localized with a spinal needle. A scalpel may be used to create a small incision through the rotator cuff tendon in line with its fibers to promote egress of calcific debris. Surrounding tissue and loose debris are removed with an arthroscopic shaver. Following decompression, the rotator cuff repair is inspected, and if a bursal-sided or full-thickness tear is identified, an arthroscopic repair is performed with a construct individualized to the specific tear pattern. Results: Surgical treatment conferred greater functional improvement and comparable pain reduction to nonoperative treatments in a systematic review comprised of 27 randomized trials. While the addition of a rotator cuff repair remains controversial, combined excision of calcific tendinitis with concomitant rotator cuff repair led to greater functional outcomes and pain reduction at 2-year minimum follow-up compared with isolated decompression. Conclusion: Calcific tendinitis within the shoulder may be treated successfully with arthroscopic decompression and subsequent repair of a residual rotator cuff defect, followed by a graduated physical rehabilitation program. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Physical Therapist Interventions Versus or Combined With Surgical Treatment in Nontraumatic Degenerative Meniscal Pathology: A Systematic Review and Network Meta-Analysis.

This study aimed to synthesize the evidence from randomized clinical trials in people with nontraumatic degenerative meniscal pathology by comparing physical therapist interventions versus or combined with arthroscopic partial meniscectomy (APM). Seven electronic databases were searched. Methodological quality was evaluated using the Physiotherapy Evidence Database scale. Data synthesis was performed with random-effects network meta-analysis, and results were summarized using the standardized mean differences. From 2103 studies, 10 randomized clinical trials comprising 1411 individuals were included. Ninety percent of the selected randomized clinical trials were classified as good quality according to the Physiotherapy Evidence Database scale. All interventions (physical therapist interventions, APM, and APM plus physical therapist interventions) showed reduced pain and physical impairments at 3-month follow-up. However, when a physical therapist intervention was included, greater reductions in pain at rest (APM vs physical therapist interventions: 0.73 [95% CI = 0.20 to 1.26]; APM vs APM plus physical therapist interventions: 0.59 [95% CI = 0.15 to 1.03]) and greater increases in the strength of knee extensor muscles (APM vs physical therapist interventions: 0.44 [95% CI = 0.07 to 0.80]; APM vs APM plus physical therapist interventions: 0.73 [95% CI = 0.29 to 1.16]) were observed at 3months. By contrast, no differences were found between treatments beyond 3months. Physical therapist interventions based on exercise programs demonstrate superior short-term outcomes in pain reduction and knee extensor strength compared to surgical treatment. For nontraumatic degenerative meniscal pathology, conservative treatment utilizing a physical therapist intervention approach should be prioritized as the first choice over surgical treatment. It offers comparable or superior short-term pain reduction and strength improvements, with a lower risk of side effects. In cases where surgery is deemed necessary, including postsurgical, physical therapist interventions are highly recommended to enhance muscle strength and alleviate pain.

Comparing the Pericapsular Nerve Group Block and the Lumbar Plexus Block for Hip Fracture Surgery: A Single-Center Randomized Double-Blinded Study.

Lumbar plexus blocks (LPBs) are routinely employed for analgesia in hip fracture surgery; however, a novel regional technique, the pericapsular nerve group (PENG) block, potentially offers comparable pain reduction while preserving motor function. Patients aged 45-90 years who underwent hip fracture surgery were allocated to receive either a PENG block or an LPB for analgesia. The primary outcome was the incidence of quadriceps motor block (defined as the paresis or paralysis of the knee extension) at 12 h postoperatively. The secondary outcomes included the performance time, the time to first analgesic requirement, postoperative intravenous (IV) fentanyl consumption, the ability to undergo physiotherapy at 24 and 48 h, complications, sensory and motor block assessments, postoperative numeric rating scale (NRS) pain scores, and patient outcome questionnaires. There was a significantly lower incidence of quadriceps motor block at 6 h (26.7% vs. 80.0%; p < 0.001) and at 12 h (20.0% vs. 56.7%; p = 0.010). The PENG block provided better preservation of the sensory block as well as better performance time (p < 0.001) and time to first analgesia requirement (p = 0.034), whereas the LPB resulted in lower postoperative IV fentanyl consumption at 24 h (p = 0.013). The PENG block demonstrated superiority over the LPB in preserving quadriceps strength and patient satisfaction without any substantial complications, despite higher opioid consumption within the first 24 h post-surgery.

Chronic Calcific Tendonitis of the Rotator Cuff: A Systematic Review and Meta-analysis of Randomized Controlled Trials Comparing Operative and Non-operative Interventions.

Calcific tendinitis is a relatively common shoulder disorder, with 7% to 17% of individuals with shoulder pain having rotator cuff calcium deposits. Several nonoperative interventions, extracorporeal-shockwave-therapy (ESWT) and ultrasound-guided-needling (UGN), and surgical techniques have been described to treat calcific tendonitis with satisfactory outcomes. Clinical guidelines are lacking for surgical excision in cases refractory to nonoperative treatment. Several arthroscopic and open operative techniques have been described to treat calcific tendonitis with satisfactory clinical outcomes. The purpose of this systematic review of randomized controlled trials is to compare outcomes and complications of nonoperative versus operative management of chronic calcific tendinitis of the rotator cuff, to provide evidence-based treatment guidelines for practitioners. EMBASE, PubMed, and OVID [MEDLINE] were searched from database inception until February 20, 2022, for randomized controlled trials reporting outcomes related to operative or nonoperative management for calcific tendonitis of the shoulder. Clinical outcomes including pain on visual analog scale (VAS), Constant-Murley Shoulder Outcome Score (CMS), and resolution of calcific deposits were evaluated. Continuous data at last follow-up was pooled into mean differences using a random effects model for meta-analysis. A total of 27 studies (2,212 nonoperative patients and 140 operative patients) met the final inclusion criteria. Pooled mean difference in VAS for ESWT was -3.83 (95% Confidence Interval [CI] -5.38, -2.27); p < 0.00001), compared to -4.83 (95%CI -5.44, -4.22; p < 0.00001) for UGN, and -4.65 (95%CI -5.47, -3.82; p < 0.00001) for the operative interventions. Pooled mean difference in CMS score after ESWT was 18.30 (95%CI 10.95, 25.66; p < 0.00001) compared to 22.01 (95%CI 8.17, 35.84; p = 0.002) for UGN, and 38.35 (95%CI 31.68, 45.02; p < 0.00001) for the operative interventions. 85% of patients receiving operative and 67% of patients receiving UGN management had complete radiographic resolution of calcific deposit. Surgical treatment of chronic calcific tendonitis of the rotator cuff results in larger improvement in functional outcome scores and comparable pain reduction to nonoperative interventions, particularly UGN. Both operative and nonoperative treatment modalities are likely to have clinically significant improvements in function and pain and thus it is reasonable to trial UGN and ESWT as first-line treatment. Cost-effectiveness analyses will be needed to support one treatment over the other. High quality RCTs directly comparing nonoperative interventions to operative interventions in patients prior to failing conservative treatment are needed to establish high-quality evidence-based guidelines.

Return rates for opioid versus nonopoid management of patients with abdominal pain in the emergency department

Given the nationwide opioid epidemic, EM clinicians are in a unique position to address it by increasing the use of non-opioid analgesia, prescribing parenteral &amp; oral opioids inED &amp; at discharge with care, &amp; identifying &amp; treating studied cases with opioid use disorder while they are still in ED. In a side-by-side study of NSAIDs (valdecoxib) and opioid/acetaminophen combinations, individuals with acute MSK pain in the ED experienced comparable pain reduction for short-term analgesia (up to sixty minutes). NSAIDs had comparable analgesic efficacy to acetaminophen at one to two hours &amp; two to three days in studied cases with acute STIs as well as opioids at 1 hour (moderate certainty evidence) &amp; four to seven days (low certainty evidence). Studied cases who present to EDwith range of acute painful syndromes, various chronic painful syndromes, or pain syndromes connected to cancer receive quick &amp; efficient pain treatment using opioid analgesics. When it is determined that the chance of analgesic benefit outweighs likelihood of harm, opioids ought to be utilized in EDas part of multimodal analgesia in conjunction with non-pharmacological &amp; non-opioid therapy.

Open and arthroscopic management of femoroacetabular impingement: a review of current concepts.

Femoroacetabular impingement (FAI) is a common femoral and/or acetabular abnormality that can cause progressive damage to the hip and osteoarthritis. FAI can be the result of femoral head/neck overgrowth, acetabular overgrowth or both femoral and acetabular abnormalities, resulting in a loss of native hip biomechanics and pain upon hip flexion and rotation. Radiographic evidence can include loss of sphericity of the femoral neck (cam impingement) and/or acetabular retroversion with focal or global overcoverage (pincer impingement). Operative intervention is indicated in symptomatic patients after failed conservative management with radiographic evidence of impingement and minimal arthritic changes of the hip, with the goal of restoring normal hip biomechanics and reducing pain. This is done by correcting the femoral head-neck relationship to the acetabulum through femoral and/or acetabular osteoplasty and treatment of concomitant hip pathology. In pincer impingement cases with small lunate surfaces, reverse periacetabular osteotomy is indicated as acetabular osteoplasty can decrease an already small articular surface. While surgical dislocation is regarded as the traditional gold standard, hip arthroscopy has become widely utilized in recent years. Studies comparing both open surgery and arthroscopy have shown comparable long-term pain reduction and improvements in clinical measures of hip function, as well as similar conversion rates to total hip arthroplasty. However, arthroscopy has trended toward earlier improvement, quicker recovery and faster return to sports. The purpose of this study was to review the recent literature on open and arthroscopic management of FAI.

Comparative effects of combined physical therapy with Kinesio taping and physical therapy in patients with knee osteoarthritis: a systematic review and meta-analysis

Objective: To compare therapeutic effects between physical therapy (PT) combined with Kinesio taping (KT) and PT alone in knee osteoarthritis treatment. Data sources: PubMed, Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, CNKI, WangFang Data, and Google Scholar were searched until 16 April 2020. Review methods: Randomized controlled trials comparing pain reduction (visual analogue scale and numeric pain rating scale) and functional improvement (Western Ontario and McMaster Universities Osteoarthritis Index) between PT + KT and PT in knee osteoarthritis treatment were included. The risk of bias was assessed using the Cochrane Collaboration’s tool. Results: A total of 15 studies with 546 patients were included, and their outcomes for one to six weeks after initial treatments were compared. An overall trend favoring PT + KT over PT alone was indicated by greater pain score reduction (mean difference (MD) = −0.70, 95% confidence interval (CI) = −1.14 to −0.26; P = 0.002) and functional improvement (MD = −5.45, 95% CI = −10.23 to −0.66; P = 0.03) with the former. Significant pain reduction (MD = −0.72, 95% CI = −1.18 to −0.26; P = 0.002) and functional improvement (MD = −6.05, 95% CI = −11.18 to −0.93; P = 0.02) were reported within six weeks after initial treatments. Conclusion: Compared with PT alone, PT combined with KT provided better therapeutic effect regarding pain reduction and functional improvement in patients with knee osteoarthritis. The additional pain reduction and functional improvement could last at least six weeks after initial treatments.

Effectiveness of dienogest in improving quality of life in Asian women with endometriosis (ENVISIOeN): interim results from a prospective cohort study under real-life clinical practice

BackgroundDienogest has been shown to substantially improve endometriosis-associated symptoms such as debilitating chronic pelvic pain, and in turn, health-related quality of life (HRQoL). To date, there is no data on patient-reported outcomes reflecting the real-world practice in Asia where endometriosis is a relevant health, social and economic burden. This non-interventional, multi-center, prospective study aims to investigate the influence of dienogest on HRQoL.MethodsAsian women received dienogest (2 mg/daily) and were followed for 24 months. The effectiveness of dienogest to improve HRQoL and endometriosis-associated pelvic pain (EAPP) was assessed by patient-reported outcomes. HRQoL, especially the “pain” domain as primary endpoint, was evaluated with the Endometriosis Health Profile-30 (EHP-30) questionnaire. The numeric rating scale served to determine changes in the severity of EAPP. Within the presented interim analysis (data cut-off: 2017-11-27), the mean changes in EHP-30 and EAPP scores from baseline to 6 months upon availability of the data were evaluated. Treatment-emergent adverse events (TEAEs) and bleeding profiles were documented.ResultsDienogest therapy decreased EHP-30 scores in all assessed domains (score 0–100, lower scores indicate better HRQoL). Primarily, the “pain” domain was improved in 78.4% of patients. EAPP was reduced (score 0–10, lower scores reflect less pain), highlighted by a mean reduction of the pain score by − 4.5 points. Patients with a higher EAPP score at baseline had an increased response to dienogest (− 6.2 points mean change) compared to patients with low baseline EAPP severity (− 1.4 points mean change). Both surgically and clinically diagnosed patients described comparable pain reduction, as well as women with or without prior treatment.Drug-related TEAEs were documented for 31.5% of patients, with amenorrhoea (5.9%) and metrorrhagia (5.1%) being the most common events. The bleeding pattern was changed upon dienogest, characterized by decreased normal bleeding (84.2 to 28.8%) and increased amenorrhea (3.2 to 42.9%) at 6 months.ConclusionThe data indicate an amelioration of HRQoL and EAPP upon dienogest therapy. No new safety signals were observed. Therefore, its use as first-line therapy for long-term management of debilitating and chronic endometriosis-associated pain represents an interesting option that remains to be further investigated.Trial registrationName of registry: Clinical Trials Clinicaltrials.gov registration number: NCT02425462 Registration date: 2015-04-24. Registration timing: prospective.

(276) - Does opioid-induced nausea and vomiting (OINV) interfere with pain control?

Nausea and vomiting are distressing symptoms. Among other emetogenic medications, opioids are well-known pharmacologic causes of nausea and vomiting (i.e., OINV). Common sense suggests that OINV would interfere with pain control. Does it? What effect does OINV have on pain relief when patients are treated with a standard opioid-containing medication such as hydrocodone 7.5 mg/acetaminophen 325 mg (HC/APAP)? We had the opportunity to address this question in a randomized, double-blind, placebo-controlled trial by comparing pain reduction in patients treated with HC/APAP who developed OINV to pain reduction in patients treated with HC/APAP who did not. After unilateral first metatarsal bunionectomy with osteotomy and internal fixation without collateral procedures, adult patients were randomized under double-blind conditions to HC/APAP or placebo when they reported moderate-to-severe pain on a 0–10 numerical pain intensity rating scale. At specified intervals over the initial 48-hour post-op treatment observation period they rated the intensity of pain and nausea and documented episodes of vomiting and uses of antiemetics while taking study medication every 4–6 hours. Summed pain intensity differences were calculated over 48 hours (SPID48), in particular, to determine pain reduction in HC/APAP-treated patients with and without OINV. There were no significant clinical or demographic differences at baseline among 300 patients who were randomized to HC/APAP or placebo. OINV occurred in 45% of HC/APAP-treated patients. Mean SPID48 scores significantly differentiated HC/APAP treatment from placebo for all patients, for patients with OINV, and for patients without OINV. Mean SPID48 scores were approximately 40% lower for HC/APAP-treated patients who had OINV than for HC/APAP-treated patients who did not have OINV (P < .001). This study demonstrates that a commonly used opioid medication is significantly less effective as an analgesic for patients with OINV than patients without OINV. We conclude that OINV interferes with pain relief. Sponsored by Charleston Laboratories, Inc.

Non-steroidal anti-inflammatory drugs for sciatica.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently prescribed drugs for the treatment of sciatica. A previous Cochrane review on the efficacy of NSAIDs summarised findings for acute and chronic low back pain (LBP) and sciatica. This is an update of the original review (2008) focusing on people suffering from sciatica. To determine the efficacy of NSAIDs in pain reduction, overall improvement, and reported side effects in people with sciatica. We performed electronic searches up to 24 June 2015 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed, and two trials registers. We searched reference lists of included studies and relevant reviews on the topics for additional trials. We included randomised controlled trials (double-blind, single-blind, and open-label) that assessed the efficacy of NSAIDs in sciatica. We included all trials that compared NSAIDs to placebo, to other NSAIDs, or to other medication. Additional interventions were allowed if there was a clear contrast for the treatment with NSAIDs in the trial. Three review authors independently assessed the risk of bias and extracted the data. Where feasible we calculated pooled results using Review Manager 5.3. We reported pain relief outcomes using mean difference (MD) with 95% confidence intervals (95% CI). We used risk ratios (RR) with 95% CI to report global improvement of treatment, adverse effects, and additional medication. We performed a meta-analysis if possible. We assessed level of evidence using the GRADE approach. We used standard methodological procedures recommended by The Cochrane Collaboration. We included 10 trials reported in 9 publications (N = 1651). Only one trial out of 10 was assessed at low risk of bias. Five trials used the currently recommended daily dose for the drug, and two trials used lower daily doses available over the counter. Three trials investigated NSAIDs no longer approved for human use. The follow-up duration was short in all studies but one.Three trials (n = 918) compared the effects of NSAIDs to those of placebo on pain reduction. The pooled mean difference showed comparable pain reduction (visual analogue scale, 0 to 100) in the NSAIDs and placebo groups (MD -4.56, 95% CI -11.11 to 1.99). Heterogeneity was high (I2 = 82%), and the quality of the evidence was very low. When we excluded one trial with a short follow-up of eight hours, the mean difference further decreased (MD -0.09, 95% CI -9.89 to 9.71). Three trials (n = 753) compared NSAIDs to placebo regarding global improvement. We found low-quality evidence that NSAIDs are more effective than placebo with a risk ratio of 1.14 (95% CI 1.03 to 1.27). One trial (n = 214) studied the effect of NSAIDs on disability, finding very low-quality evidence that NSAIDs are no more effective than placebo on disability. Four trials (n = 967) comparing NSAIDs to placebo reported adverse effects, with low-quality evidence that the risk for adverse effects is higher in the NSAID group than in the placebo group (RR 1.40, 95% CI 1.02 to 1.93). The adverse effects reported in this review are consistent with those previously reported in the literature. This updated systematic review including 10 trials evaluating the efficacy of NSAIDs versus placebo or other drugs in people with sciatica reports low- to very low-level evidence using the GRADE criteria. The efficacy of NSAIDs for pain reduction was not significant. NSAIDs showed a better global improvement compared to placebo. These findings must be interpreted with caution, as the level of evidence according to the GRADE classification was very low for the outcome pain reduction and low for global improvement due to small study samples, inconsistent results, imprecision, and a high risk of bias in the included trials. While the trials included in the analysis were not powered to detect potential rare side effects, we found an increased risk for side effects in the short-term NSAIDs use. As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug needs to be considered.

Exposure-response modeling of average daily pain score, and dizziness and somnolence, for mirogabalin (DS-5565) in patients with diabetic peripheral neuropathic pain

Mirogabalin (DS-5565) is an α2δ-1 ligand being developed for pain associated with diabetic peripheral neuropathy, fibromyalgia, and postherpetic neuralgia. Nonlinear mixed-effects analyses were performed on average daily pain and on the incidence of the adverse events dizziness and somnolence. These models were used to predict the dose of mirogabalin equivalent to pregabalin and the probability of meaningful reduction in pain compared with placebo and pregabalin. In addition, regimen effects were evaluated for reductions of adverse events. Mirogabalin was estimated to be 17-fold more potent than pregabalin. The effectiveness of 150 mg pregabalin, dosed twice daily, attenuated by week 5. Therefore, the estimated mechanism-based equivalent dose (ED) of 17.7 mg mirogabalin was higher than that predicted to achieve comparable pain reduction. If attenuation of the pregabalin effect is real, mirogabalin doses lower than the ED could yield comparable pain reduction, albeit with less differentiation in pain from placebo. The incidence rate of dizziness and somnolence decreased over time. Twice-daily dosing of mirogabalin was predicted to yield a lower incidence rate of dizziness than once-daily dosing; thus, titration of dosages should reduce adverse event rates. These model results were used to influence phase 3 dosing selection.

Comparing Pain Reduction Following Vertebroplasty and Conservative Treatment for Osteoporotic Vertebral Compression Fractures: A Meta-Analysis of Randomized Controlled Trials

Background: Osteoporotic vertebral compression fractures (OVCFs) are the most common osteoporotic fractures. Pain is the main symptom. Percutaneous vertebroplasty (PVP) is a therapeutic procedure performed to reduce pain in vertebral compression fractures. Numerous case series and several small, non-blinded, non-randomized controlled studies have suggested that vertebroplasty is an effective means of relieving pain from osteoporotic fractures. However, a recent pooled analysis from 2 multicenter randomized controlled trials concluded that the improvement in pain afforded by PVP was similar to placebo. Objective: To compare the amount of pain reduction measured using the visual analog scale when OVCF is treated with vertebroplasty or conservatively, and assess the clinical utility of PVP. Design: A meta-analysis and systematic review of randomized controlled trials was performed comparing pain reduction following vertebroplasty and conservative treatment. Limitations: There were few data sources from which to extract abstracted data or published studies. There were only 5 randomized controlled trials that met our criteria. The conservative treatments used as comparators in these trials were different. Methods: A search of MEDLINE from January 1980 to July 2012 using PubMed, the Cochrane Database of Systematic Reviews and Controlled Trials, CINAHL, and EMBASE. Relevant reports were examined by 2 independent reviewers and the references from these reports were searched for additional trials, using the criteria established in the QUOROM statement. Results: Pooled results from 5 randomized controlled trials are shown. There was no difference in pain relief in the PVP group at 2 weeks and one month when compared with the conservatively managed group. Pain relief in the PVP group was greater than that of the conservative group at 3 months, 6 months, and 12 months. However, after subgroup analysis, pain scores were similar between the PVP group and the sham injection group from 2 weeks to 6 months. Compared with non-operative therapy, PVP reduced pain at all times studied. Conclusion: PVP has some value for relieving pain; however, the possibility of a placebo effect should be considered. PVP has gained acceptance as a complementary treatment when conservative management has failed before its benefits have been fully understood. More large scale, double blinded, controlled trials are necessary in order to quantify the pain relief afforded by PVP more precisely. Key words: Vertebroplasty, osteoporosis, vertebral compression fracture, randomized controlled trials, systemic review, meta-analysis

Evaluation of the effectiveness of a semi-finished occlusal appliance – a randomized, controlled clinical trial

IntroductionPainful temporomandibular disorders (TMDs) are usually treated with physiotherapy, self-exercises, medication-based therapy and splint therapy. For splint therapy different types of splints are available. Therefore this randomized controlled study compared the effectiveness of a semi-finished occlusal appliance (SB) with a laboratory-made occlusal appliance (SS) in myofascial pain patients.MethodThe trial subjects allocated to the experimental groups with the (SB) occlusal appliance and those provided with a laboratory-made occlusal appliance (SS) did, in addition, receive conservative treatment (self-exercises, drug-based and manual therapy). The control group was given conservative therapy (CO) only. Overall, a total of 63 patients participated in the study with each group consisting of 21 subjects.ResultsWhen the first follow-up examination took place (14 days after splint insertion) mouth opening within the SB group was significantly enlarged. When the second examination was conducted (2.5 months after splint insertion) mouth opening was significantly enlarged in both splint groups when compared with the initial value. In the control group, no significant enlargement of mouth opening was detected. At no point there was a significant reduction in the number of pressure-sensitive areas of the TMJ. On palpation of the masticatory muscles however, a significant reduction in the number of pressure-sensitive areas could be observed within the CO group and the SS group after 2.5 months.When comparing pain reduction (muscle/joint pain) and mouth opening, no significant differences could be detected between the treatments.ConclusionThe results suggest that TMD should be treated conservatively. In cases of restricted mouth opening, the additional use of occlusal appliances can eliminate the patient’s discomfort more quickly. In this context, the tested, semi-finished occlusal appliance appears to offer an immediately available, temporary alternative to laboratory-made splints.

An RCT of varying oral contraceptive regimens in the treatment of primary dysmenorrhea

Primary dysmenorrhea (PD) is the most common cause of pelvic pain in women. Oral contraceptives (OCP) are frequently prescribed, but not always effective. We theorized that cyclic OCP which induces withdrawal bleeding allows the production of prostaglandins and persistent pain. Continuous OCP (COCP) has not been studied as a primary treatment of PD, although recent studies show its superiority to traditional regimens in the treatment of endometriosis. We hypothesized that continuous OCP will result in more pain relief than cyclic administration in PD patients. A double-blind, randomized controlled trial (RCT) comparing COCP to a cyclic 21/7 regimen for 6 months in PD patients. We conducted a trial of two treatment regimens of a monophasic OCP (gestodene 0.075 mg/ethinyl estradiol 20 mcg) in 38 PD patients. The primary outcome was the difference in subjective perception of pain as measured by the Visual Analog Scale (VAS) over the period of six months, as analyzed by a mixed-effects model to account for the within-subject correlation over time. 33 patients completed the study. Mean VAS score (SD) in the cyclic regimen was 64.4 (31.9) at screening visit, 19.0 (24.8) after one month, and 5.2. (9.5) at the end of the study. Mean VAS score in the COCP group was 75.6 (16.7) at screening visit, 3.1 (5.8) after one month, and 0.8 (1.4) at the end of the study. In both groups pain reduction measured by VAS was significant compared to baseline. COCP regimen was superior to cyclic regimen when comparing pain reduction after one (mean difference: -27.3; 95% CI: (-40.5,-14.2); P<0.001) and three (mean difference: -17.8; 95% CI: (-33.4,-2.1); P=0.03) months of treatment, and almost reached statistical significance after six (mean difference: -16.0; 95% CI: (-32.2,0.1); P=0.05) months of treatment. Although both regimens of OCP are efficient in the treatment of PD, COCP regimen is superior to cyclic OCP in the short term.

Pain relief in women with fibromyalgia: A cross-over study of superficial warmth stimulation and transcutaneous electrical nerve stimulation

To compare the effects of portable superficial warmth with transcutaneous electrical nerve stimulation on pain in patients with fibromyalgia. The study had a randomized cross-over design. A total of 32 patients with fibromyalgia were randomly assigned to 2 groups. After instruction, the patients treated themselves using a portable device providing superficial warmth (42 degrees C) or a transcutaneous electrical nerve stimulation apparatus. After 3 weeks the patients switched therapy. The patients rated pain intensity on a 0-100 numerical rating scale before and after each treatment. After 6 weeks, patients were questioned concerning therapy preference. There was no difference in level of pain relief when comparing the 2 treatment modes. Median pain intensity in patients using warmth therapy decreased from 77.5 on the numerical rating scale before treatment to 62.5 after treatment and in patients using transcutaneous electrical nerve stimulation from 80 to 62.5. Ten patients reported a reduction of 20 units or more on the numerical rating scale after warmth therapy, as did 10 after transcutaneous electrical nerve stimulation. Seventeen of 32 patients preferred warmth therapy and 10 preferred transcutaneous electrical nerve stimulation. Sensory stimulation with superficial warmth or transcutaneous electrical nerve stimulation yielded comparable temporary pain reduction in patients with fibromyalgia. Both procedures are self-administered, safe and in-expensive.

Comparing Pain Reduction Following Kyphoplasty and Vertebroplasty for Osteoporotic Vertebral Compression Fractures

Background: Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures. Although many patients heal with conservative treatment consisting of rest or activity modification, analgesics, and bracing, the management of severe pain compels some patients to seek surgical intervention via 2 procedures: vertebroplasty and kyphoplasty. Although there is abundant support in the literature for both procedures, there remains debate over which procedure can most successfully reduce patients’ perception of pain. Objective: To determine the amount of pain reduction using the visual analog scale (VAS) with kyphoplasty and vertebroplasty in the treatment of osteoporotic vertebral compression fractures. Design: Meta-analysis Methods: A systematic review and meta-analysis of the available literature was performed to quantify the amount of pain reduction using the visual analog scale (VAS) between vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures. Results: Twenty-one studies, 14 vertebroplasty and 7 kyphoplasty, qualified for inclusion representing totals of 1,046 vertebroplasty and 263 kyphoplasty patients treated, respectively. Kyphoplasty and vertebroplasty resulted in a more than 5 point drop in the VAS in the immediate postoperative period (p&lt;0.00001). Between the two, the difference in early pain relief was not significant. At final follow-up, the long-term VAS was improved for both procedures, but the final follow-up VAS for vertebroplasty and kyphoplasty was not significant when compared to the initial postoperative VAS (p=0.25, p=0.38, respectively). Conclusions: The analysis demonstrates that both procedures reduce the amount of pain in the immediate postoperative period by approximately 50%. Both procedures reduce pain in symptomatic osteoporotic vertebral compression fractures that have failed conservative treatment. Randomized controlled trials are needed to provide definitive data on which procedure is the most effective for vertebral compression fractures. Key words: vertebroplasty, kyphoplasty, vertebral compression fracture, osteoporosis