Decrease In Visual Analog Scale Score Research Articles

Efficacy of milnacipran in the treatment of chronic pain syndromes

Eleven outpatients with chronic pain syndromes other than fibromyalgia were treated for 12 weeks with milnacipran, a novel serotonin noradrenaline reuptake inhibitor. The agent was administered at 50–150 mg/day, and the mean ± SD dose at 12 weeks or at the time drug treatment was stopped was 84.1 ± 32.2 mg/day. None of the patients met the DSM-IV criteria for a major depressive disorder. Abdominal, chest, back, arm, leg or glossal pain, or headache was involved. Pain was assessed clinically by means of a visual analog scale (VAS) before and 12 weeks after the start of milnacipran treatment, or at the time drug treatment was stopped. The mean ± SD decrease in VAS scores was 42.3 ± 31.6 (50.8 ± 49.2%). One patient discontinued treatment after 4 weeks because of nausea, whereas others tolerated the agent well. These results suggest that the use of milnacipran in patients with a variety of chronic pain syndromes is beneficial.

Bloqueo tricompartimental del hombro doloroso: estudio preliminar

Introduction Painful shoulder is one of the most common reasons for consulting in primary care and affects between 7% and 34% of the general adult population. The most frequent etiology is rotator cuff dysfunction, accounting for over 70% of cases, including tendinitis, bursitis and rupture of the rotator cuff or any of its components. Various treatments have been proposed for painful shoulder. The aim of this study was to present a new technique for patients refractory to conventional treatments. Material and methods We analyzed the efficacy of the technique using a visual analog scale (VAS), administered to patients at baseline and 1 month later. In the same period, we evaluated patient satisfaction and the percentage of improvement. Finally, we analyzed complications, if any, and the patients were asked if they would repeat the process or not. Results The technique was performed in 12 patients. The mean baseline VAS was 8.5 ± 1, which decreased to 5.5 ± 3 after the procedure. In patients who benefitted from the procedure, the decrease in VAS score was close to 5 points with respect to baseline. The technique seemed to be more effective in patients with arthrosis than in those mainly with soft tissue involvement. The mean improvement in the entire sample was 45.83 ± 42.05. Seven patients reported they would repeat the technique compared with five who reported they would not. No complications resulted from the procedure. Conclusions Tricompartmental blockade of the shoulder seems to be a promising technique in the treatment of shoulder pain, especially when the underlying disease is degenerative.

Efficacy of purslane in the treatment of oral lichen planus

This study evaluated the effectiveness of antioxidant-rich purslane in the treatment of oral lichen planus (OLP). A total of 37 biopsy-proven symptomatic OLP patients were selected for this randomized double-blind placebo-controlled trial. All subjects were divided into two groups to receive purslane (n = 20) or placebo (n = 17) for 3 months. Assessments were made at baseline, after 2 weeks and each month for 6 months, based on the visual analog scale (VAS) and clinical improvement including lesion type and size. Approximately 83% of the purslane patients showed partial to complete clinical improvement but 17% had no response. In the placebo group 17% experienced partial improvement, 73% did not respond and 10% showed worsening. According to VAS scores, a partial to complete response was observed in all purslane-treated patients, while 71%, 15% and 14% of the controls demonstrated partial response, no response and worsening of the symptoms, respectively. A significant decrease in VAS scores was seen at the end of the study period (p < 0.001). No serious side-effects occurred in either of the groups. According to our findings purslane is clinically effective in the treatment of OLP. Considering the lack of side-effects during the study period, it may be a favorable alternative treatment for OLP.

Acupuncture for Treating Acute Attacks of Migraine: A Randomized Controlled Trial

To discuss the results of a multicenter randomized controlled trial of the efficacy of verum acupuncture in treating acute migraine attacks. Acupuncture has been used in China for centuries to treat migraine headache. Convincing evidence of its efficacy in alleviating pain, however, has been inadequate to date. A total of 218 patients with migraine were recruited for the study; 180 met the inclusion criteria; 175 completed the callback process and were randomized into 3 groups. One group received verum acupuncture while subjects in the other 2 groups were treated with sham acupuncture. Each patient received 1 session of treatment and was observed over a period of 24 hours. The main outcome measure was the differences in visual analog scale (VAS) scores before treatment and 0.5, 1, 2, and 4 hours after treatment. Significant decreases in VAS scores from baseline were observed in the fourth hour after treatment when VAS was measured in the patients who received either verum acupuncture or sham acupunctures (P < .05). The VAS scores in the fourth hour after treatment decreased by a median of 1.0 cm, 0.5 cm, and 0.1 cm in the verum acupuncture group, sham acupuncture group 1, and sham acupuncture group 2, respectively. Similarly, there was a significant difference in the change in VAS scores from baseline in the second hour after treatment among the 3 groups (P = .006). Moreover, at the second hour after treatment, only patients treated with verum acupuncture showed significant decreases in VAS scores from baseline by a median of 0.7 cm (P < .001). Significant differences were observed in pain relief, relapse, or aggravation within 24 hours after treatment as well as in the general evaluations among the 3 groups (P < .05). Most patients in the acupuncture group experienced complete pain relief (40.7%) and did not experience recurrence or intensification of pain (79.6%). Verum acupuncture treatment is more effective than sham acupuncture based on either Chinese or Western nonacupoints in reducing the discomfort of acute migraine. Verum acupuncture is also clearly effective in relieving pain and preventing migraine relapse or aggravation. These findings support the contention that there are specific physiological effects that distinguish genuine acupoints from nonacupoints.

Evaluation of the effect of locally administered amitriptyline gel as adjunct to local anesthetics in irreversible pulpitis pain

Amitriptyline is one of the most common tricyclic antidepressants, which binds to pain sensory nerve fibers close to the sodium channel; hence, it could interact to some degree with receptors of local anesthetics. This study was designed to assess the additional analgesic effects of 2% Amitriptyline local gel administration in irreversible pulpitis pain of the molars. This study was a randomized, double-blind clinical trial that was performed on 56 consented adult patients who did not receive enough analgesia after a lidocaine nerve block for their tooth pulpitis pain. Patients were treated with 0.2 ml of either 2% amitriptyline or placebo, which was directly injected into their mandibular molar pulp chamber after they had received two routine lidocaine injections. Patients were asked to score their pain as a mark on a 10-cm Visual Analogue Scale (VAS) at different timepoints: 0 (just before gel administration), 1, 3, 5, 7, and 9 minutes after the treatments. There was a 92.5% decrease in VAS scores of patients 9 minutes after amitriptyline administration compared to Time 0, while in the placebo group this difference was only 13.5%. Further, in the amitriptyline group, the VAS score at all timepoints was statistically different from Time 0 (P < 0.01). The overall pain reduction and its trend was significantly higher in the amitriptyline group compared with the placebo group (P < 0.001). Inter-pulp space administration of amitriptyline 2% gel for completing analgesia in irreversible pulpitis pain could be effective and useful as a conjunctive therapy to injections of local anesthetics.

Pain treatment and relief among patients with primary headache subtypes in the ED

Objective The aim of this study is to determine if emergency physicians treat headache subtypes differently and if this difference affects pain relief. Methods This was a prospective observational, institutional review board–approved study of adults undergoing treatment for a primary headache. Before the treatment and 60 minutes after, patients completed a 100-mm Visual Analog Scale (VAS) describing their pain. Patients also completed a headache diagnosis worksheet that differentiated headache type based on International Headache Society criteria. Treatments were recorded. Data were analyzed using descriptive statistics, 95% confidence intervals, analysis of variance, and χ 2 tests as appropriate. Results A total of 184 patients were enrolled: 83 (45.1%) with migraine, 61 (33.2%) with migrainous, and 40 (21.7%) with tension-type headaches. There was no difference in the presenting VAS score or treatments of the 3 headache subtypes. The migraine group was most likely to receive any pain medication (78.31%), and the tension group the least likely to receive any pain medication (62.50%). A 50% decrease in VAS was achieved by only 32.5% of the patients. Sumatriptan, followed by droperidol, provided the greatest decrease in VAS scores. Oral and parenteral narcotics provided equivalent pain relief, with nonsteroidal anti-inflammatory drugs (NSAIDs) providing the least pain relief. Conclusion There was no difference in the treatments used or pain relief achieved between migraine, migrainous, and tension-type headaches. The differentiation of primary headache subtypes does not appear to be important to their treatment in the acute setting of the emergency department.

Olanzapine versus Droperidol for the Treatment of Primary Headache in the Emergency Department

The objective was to determine if there is a difference in pain relief or frequency and severity of side effects in emergency department (ED) patients with primary headache treated with either intramuscular (IM) olanzapine or IM droperidol. This was a prospective, randomized nonblinded clinical trial of adult ED patients undergoing treatment for suspected primary headache. Consenting patients were randomized to receive either droperidol 5 mg IM or olanzapine 10 mg IM. Prior to receiving treatment, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain and a 4-point verbal rating scale (VRS) describing their pain as none, mild, moderate, or severe. Patients also completed a 100-mm VAS describing their level of nausea. Pain and nausea measurements were repeated 30 and 60 minutes after medication administration. Patients also completed the Barnes Akathisia Scale (BAS) 30 and 60 minutes after medication administration. Descriptive statistics were used as appropriate. Pain relief was compared both in terms of the decrease in VAS scores and in the proportion of patients who reported moderate or severe pain whose report later changed to mild or no pain. One-hundred patients were enrolled; 13 were withdrawn before administration of the study medication, 8 in the droperidol group and 5 in the olanzapine group, leaving 87 patients for analysis. Forty-two patients received droperidol and 45 received olanzapine. In the droperidol group, 35/40 (87.5%) patients who had reported moderate or severe pain at baseline reported mild or no pain at 60 minutes. In the olanzapine group, 38/44 (86.4%) reported this change (p = 0.89). The mean percent change from baseline VAS pain score at 60 minutes was -37% (95% CI = -84% to 11%) for droperidol and -37% (95% CI = -64% to 10%) for olanzapine (p = 0.30). The mean percent change from baseline for the VAS nausea score was -59% (95% CI = -70% to -47%) for droperidol and -64% (95% CI = -77% to -51%) for olanzapine (p = 0.83). There was no difference in any report of akathisia by the BAS between the groups (p = 0.63). Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol.

Revision Lumbar Arthrodesis for the Treatment of Lumbar Cage Pseudoarthrosis: Complications

A study documenting major complications encountered in revision procedures for lumbar cage pseudoarthrosis. To document the perioperative complications associated with revision surgery for threaded cylindrical cage pseudoarthrosis. Pseudoarthrosis after cylindrical cage placement manifests as persistent or recurrent pain and disability after surgery. Revision strategies include isolated posterior stabilization and posterior bone grafting, versus circumferential revision where an attempt is made to remove the cages anteriorly, followed by posterior stabilization and fusion. Potential complications associated with these revision procedures have not been adequately documented in the past. Forty-seven consecutive patients with the diagnosis of cylindrical cage pseudoarthrosis were surgically treated with either a circumferential revision (AP) or an isolated posterior instrumented fusion (P). All intraoperative and postoperative complications were documented. Radiographic interbody fusion rates and preoperative and postoperative visual analog scale (VAS) scores were documented. Three of the AP patients, all with anterior cage placement at L5-S1, had iliac vein lacerations requiring repair. A fourth patient had a ureteral injury requiring subsequent nephrectomy. Three patients who underwent circumferential revision and 2 patients who had an isolated posterior procedure had postoperative complications, including 2 infections (1 AP and 1 P), 1 radiculopathy (P), and 2 patients with prolonged ileus (both AP). There was a statistically significant decrease in overall VAS scores postoperatively for the 2 groups using the paired t test (P<0.0001). There was no difference in either the preoperative (P=0.22) or 2-year postoperative (P=0.30) VAS scores between the AP and P groups [rank-sum (Mann-Whitney) t tests]. Interbody fusion was achieved in 79% (30 of 38 levels) in the AP group. The interbody fusion rate was 37% (8 of 22) for the P group. Circumferential revision including cage removal, structural allograft placement, and posterior stabilization is associated with increased perioperative complications. Although an anterior approach showed increased interbody fusion rates, this technique did not lead to more superior clinical outcomes based on VAS scores. It remains to be shown by larger prospective studies if there is a true difference in outcome between these 2 groups that will justify the increased perioperative morbidity associated with attempted cage removal.

Octreotide in Palliative Treatment of Hepatic Metastases: Is it Effective for Clinical Stabilization?

Octreotide in Palliative Treatment of Hepatic Metastases: Is it Effective for Clinical Stabilization?

Paroxetine improves pain and depression in patients with refractory chronic pain

Objective: Patients with chronic pain frequently have depression, which may augment their pain. The selective serotonin re-uptake inhibitor, paroxetine, is widely used in the treatment of depression. The purpose of this study was to examine the effectiveness of paroxetine in the treatment of refractory chronic pain. Patients and methods: Fifty patients with a history of at least 6-month persistent chronic pain participated in this study. Paroxetine was orally administered once daily at a dose of 10 mg initially, then increased weekly by 10 mg until a maximum of 40 mg. The dose was reduced when an adverse reaction occurred, and treatment was continued for 2 weeks at the optimal dose. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The state of depression was evaluated using the Self-Rating Depression Scale (SDS), and that of pain using the Visual Analogue Scale (VAS). Results: Overall, 70% of the patients had depression. The SDS score was higher in patients with depression compared with non-depressed patients. Treatment of patients with depression by paroxetine resulted in reduction of VAS score to less than half, concomitant with a decrease in SDS score. Paroxetine also significantly reduced the VAS scores in non-depressive patients. However, the decrease in VAS score was more marked in patients with depression compared to those without depression. Conclusions: These results suggest that a large proportion of patients with refractory chronic pain has depression and paroxetine improves both the depression and chronic pain.

Possible Roles of Epidermal Opioid Systems in Pruritus of Atopic Dermatitis

The micro-opioid (beta-endorphin/micro-opioid receptor) and kappa-opioid (dynorphin A (DynA)/kappa-opioid receptor) systems play pivotal roles in the modulation of pruritus in the central nervous system. The micro-opioid system has also been identified in human epidermis, raising the possibility that the system controls the peripheral itch. However, the precise distribution of the kappa-opioid system has not yet been clarified in human epidermis. To address this issue, reverse transcription-PCR and immunohistochemical analyses were performed on cultured keratinocytes and normal skins from humans. The analyses revealed that epidermal keratinocytes express kappa-opioid receptor and its ligands, DynA (1-17) and DynA (1-8). Moreover, expression for micro- and kappa-opioid systems was examined immunohistochemically in skin biopsies from healthy volunteers and patients with atopic dermatitis (AD) before and after psoralen-ultraviolet A (PUVA) therapy. Our expression analyses showed that only the kappa-opioid system, not the micro-opioid system, was downregulated in the epidermis of AD patients. The downregulation of the micro-opioid system and the restoration of the kappa-opioid system by PUVA therapy were observed in the AD patients, concomitant with a decrease of VAS (visual analogue scale) scores. These results suggest epidermal opioid systems are associated with the modulation of pruritus in AD. This new finding may help us to understand the control mechanism of peripheral itch.

Single-Dose Intravenous Tramadol for Acute Migraine Pain in Adults: A Single-Blind, Prospective, Randomized, Placebo-Controlled Clinical Trial

Background: Tramadol, an atypical opioid, is a narcotic analgesic used for pain management. A search of the current literature found no studies examining the efficacy of intravenous tramadol on migraine pain. Objective: The aim of this study was to investigate the efficacy and tolerability of a single dose of intravenous tramadol hydrogen chloride 100 mg in comparison with placebo in patients presenting with migraine. Methods: Adult migraineurs admitted consecutively to the emergency department of the Kocaeli University Hospital were enrolled in this single-blind (patients), prospective, randomized, placebo-controlled clinical trial. Patients were randomized to receive a 30-minute infusion of either intravenous tramadol (n = 17; 100 mg in 100-mL saline) or placebo (n = 17; 100-mL saline). Pain response was defined as a decrease of visual analogue scale (VAS) (0–100 mm) score to <50% of the pretreatment (baseline) value and a decrease of 4-point verbal scale (FPVS) score (0 = none, 1 = mild, 2 = moderate, 3 = severe) to mild or none. Pain-free response was defined as a decrease of both VAS and FPVS scores to 0. Pain was assessed at baseline and at 30 minutes and 1 hour after treatment completion. Migraine symptoms (eg, photophobia, phonophobia, nausea, vomiting) and adverse events (AEs) were assessed at the same time. A follow-up was also conducted by phone 24 hours after treatment. Results: Forty-four migraineurs were screened and 34 (28 women and 6 men; mean [SD] age, 39.5 [10.4] years; all were white) were enrolled in the study. Each group contained 11 patients with severe pain and 6 patients with moderate pain at baseline FPVS. At the end of 1 hour, pain response was reported by significantly more patients in the tramadol group than in the placebo group (12 [70.6%] vs 6 [35.3%]; P = 0.040). Pain-free response was reported by 5 (29.4%) patients in the tramadol group and 2 (11.8%) patients in the placebo group, although the difference was not statistically significant. Symptoms associated with migraine were also relieved in all patients reporting pain response. No AEs were observed. However, at the 24-hour follow-up, 1 patient in the tramadol group reported transient blurred vision and dizziness within the day of infusion. Headache recurrence was reported by 2 (16.7%) of the 12 patients with pain response in the tramadol group and 1 (16.7%) of 6 patients with pain response in the placebo group. Conclusions: Intravenous tramadol appeared to be more effective than placebo in pain response rate at the end of the first hour. The slow infusion of tramadol 100 mg in 100-mL saline solution was well tolerated in this group of adult migraineurs.

Clinical Trial of 3 Days of Treatment with Oral Pseudoephedrine for the Common Cold in the Southern Hemisphere

Single-dose studies indicate that pseudoephedrine (PSE) provides moderate relief for congestion in coryza, but there is a lack of repeated-dose studies. Two hundred sixteen subjects participated in this double-blind, randomized placebo-controlled trial over 3 days. Measurements included posterior rhinomanometry, acoustic rhinometry, and subjective measures of congestion using a categorical scale and visual analog scale (VAS). Treatment was with one 60-mg PSE tablet four times daily or matching placebo. After the first dose, PSE relative to placebo consistently showed small improvements for all objective assessments of nasal congestion. The prespecified primary efficacy outcome (day 1 nasal airway resistance area under the curve) was not significantly different between groups. PSE produced a 5.5% (p = 0.031) increase in total nasal volume for 0.5-3 hours after dosing. A pooled analysis of days 1 and 3 data showed a VAS score decrease of 7.0% (p = 0.072) for the 0.5- to 3-hour period on PSE. PSE showed small but nonsignificant improvements in objective assessments of nasal congestion relative to placebo after a single dose.

Analgesic treatment and predictors of satisfaction with analgesia in patients with acute undifferentiated abdominal pain

The objectives of this prospective, observational cohort study were to examine current practice of analgesia in adults with acute abdominal pain presenting to emergency department (ED), to assess patient–physician agreement on pain severity, and to measure patients’ satisfaction with pain management. Methods Emergency room nurse assessed initial patient’s and physician’s ranking on a 0–100 mm visual analogue scale (VAS) as well as patient’s VAS rankings 5 min, 15 min, and 60 min after starting treatment for pain, and on discharge. In patients who received no therapy VAS scores were assessed 5 min, 15 min, and 60 min after initial examination, and on discharge. Patient’s satisfaction with pain management on discharge from ED was assessed using a four-point categorical scale in which 1 = completely unsatisfied, 2 = mostly unsatisfied, 3 = mostly satisfied, and 4 = completely satisfied. Results A total of 185 patients were enrolled. Patients’ mean initial VAS was higher than physicians’ (76 ± 20 mm, vs. 59 ± 20 mm, p < 0.001). Physician’s VAS ⩾60 mm was the sole independent predictor of receiving analgesic therapy ( p < 0.001). On discharge from ED, 111 patients (60%) were predominantly satisfied with analgesia (satisfaction score ⩾3). Drug titration ( p = 0.026) and decrease in VAS score ⩾20 mm between initial and discharge score ( p < 0.001) independently predicted patients’ satisfaction. Conclusions Patients with acute abdominal pain rated pain significantly higher than physicians who’s pain estimation in turn tailored analgesia. Only 60% of patients were satisfied with analgesia. Analgesic drug titration and a decrease of ⩾20 mm on VAS predicted patients’ satisfaction.

Effectiveness of Milnacipran for the Treatment of Chronic Pain

Milnacipran is a novel serotonin noradrenaline reuptake inhibitor. The authors describe the use of milnacipran for the treatment of chronic pain in a series of patients. There were 5 outpatients who suffered chronic pain for at least 3 months. None of these patients met the DSM-IV criteria for a major depressive disorder. Chronic pain was assessed clinically by means of a visual analog scale (VAS) before and 12 weeks after the start of the milnacipran treatment or at the time the drug was stopped. The duration of pain was 17.8 +/- 9.3 months (mean +/- SD), and the baseline VAS score was 88.2 +/- 6.3 points. Milnacipran was administered at 50 to 150 mg/day, and the dose at 12 weeks or at the time the drug was stopped was 85.0 +/- 31.3 mg/day. The mean +/- SD decrease in VAS at this time was 61.2 +/- 15.5%. Three patients showed marked improvement (decrease in VAS, >75%). Their decreases in VAS scores were 86.5%, 85.7%, and 77.6%. One patient showed mild improvement (42.0% decrease in VAS). These 4 patients tolerated the drug well. The fifth patient experienced nausea and discontinued treatment after 4 weeks. The VAS decrease for this patient was 14.3%. Results of this study show milnacipran to be beneficial in patients with chronic pain. This drug should be studied further for its effectiveness in the treatment of chronic pain.

A Comparative Study on the Effects of Naltrexone and Loratadine on Uremic Pruritus

Background: Two recent studies have provided opposite results on the efficacy of naltrexone on uremic pruritus. We have performed a third study. Objective: To compare the efficacy and tolerance of naltrexone and loratadine in uremic pruritus. Patients/Methods: Among 296 hemodialyzed patients, 65 suffered from uremic pruritus. Fifty-two patients participated in the study. The patients were treated for 2 weeks with naltrexone (50 mg/day; 26 patients) or loratadine (10 mg/day; 26 patients), after a washout of 48 h. Pruritus intensity was scored by a visual analogue scale (VAS). Adverse events were carefully searched for. The two groups were statistically equivalent. Results: There was no significant difference in the mean VAS scores after treatment, but naltrexone allowed a dramatic decrease in VAS scores (Δ >3/10) in 7 patients. Adverse events (mainly nausea and sleep disturbances) were observed in 10/26 patients. Conclusions: Naltrexone is effective only in a subset of patients. Adverse events are very frequent. The differences of efficacy and tolerance between patients might be due to metabolism. Naltrexone might be considered as a second-line treatment.

Anticonvulsants: Oxcarbazepine in painful diabetic neuropathy: A randomized, placebo-controlled study

Preliminary studies suggest that oxcarbazepine, a newer antiepileptic drug, provides analgesia in neuropathic pain conditions. This multicenter, placebo-controlled study evaluated the efficacy and safety of oxcarbazepine monotherapy for the treatment of pain associated with diabetic neuropathy. The study comprised a 2-week pre-randomization screening phase and 16-week double-blind (DB) treatment. Eligible patients were ≥18 years old with diabetes mellitus (type 1 or 2), had symptoms of neuropathic pain from between 6 months and 5 years and a pain rating of ≥50 units on the Visual Analog Scale (VAS). The primary efficacy variable was average VAS score for pain severity during the last week of DB treatment. In total, 146 patients (oxcarbazepine, n=69; placebo, n=77) were randomized. The mean (SD) oxcarbazepine dose during the maintenance period was 1445 mg/day (389 mg/day). After 16 weeks, oxcarbazepine-treated patients experienced a larger decrease in the average change in VAS score from baseline compared with placebo (−24.3 vs −14.7 points, respectively; p=0.01). Onset of therapeutic effect occurred earlier in oxcarbazepine-treated patients compared with placebo (22.5 vs 30.7 days, p=0.02), and a greater proportion experienced a ≥20-unit decrease in daily VAS score from baseline on 2 consecutive days during DB treatment compared with placebo (56.5% vs 46.8%, respectively; p=0.02). Nearly half (48%) of oxcarbazepine-treated patients had a ‘very much’ or ‘much’ improved global assessment of therapeutic effect rating compared with placebo (22%; p=0.0025). The mean proportion of days patients were awakened during the night due to pain was lower in the oxcarbazepine-treated patients compared with placebo (0.31 vs 0.49 days; p=0.02). Adverse events were mild to moderate in severity and in line with the known tolerability profile of oxcarbazepine. These data demonstrate the efficacy and reliability of oxcarbazepine monotherapy, a potential new treatment for neuropathic pain of diabetic origin.

Poster 98: Percutaneous neuromodulation therapy for the treatment of spinal (lumbar and cervical) pain patients with radiating pain

Objective: To evaluate, within a clinical research setting, the proposed percutaneous neuromodulation therapy (PNT) mechanism of action hypothesizing that patients with centrally facilitated pain benefit more from PNT than do other patients. Design: Analysis of pooled data collected during 3 prospective clinical trials. Setting: Outpatient pain treatment centers. Participants: 119 patients enrolled in clinical trials of PNT for subacute and chronic spinal pain (lumbar or cervical) with radiating pain. Patients were clinically grouped as having probable primary: (1) nociceptive pain due to a recurrent structural source such as disk protrusion, (2) centrally facilitated pain in absence of a defined structural problem such as fibromyalgia or myofascial pain, or (3) pain from a combination of both categories (recurrent structural plus centrally facilitated). Interventions: Patients received ≥4 PNT treatments and were followed approximately 1 week after completion of the last treatment. Main Outcome Measures: Pain ratings on a 10-cm visual analog scale (VAS). Results: A multivariate analysis of variance suggested that decrease in VAS scores was dependent on pain categorization ( P=.008). Patients with centrally facilitated pain had the greatest VAS decrease and patients with recurrent structural pain had the least. Similar baseline VAS scores were noted between the groups (centrally facilitated, 5.9±1.9; recurrent structural, 6.0±1.7; recurrent structural + centrally facilitated, 6.2±1.4). Compared with recurrent structural patients, centrally facilitated patients reported lower VAS ratings ( P=.05) after their last treatment (centrally facilitated, 3.2±2.1; recurrent structural, 4.5±2.5; recurrent structural + centrally facilitated, 4.1±2.4), and marginally significant greater decrease in VAS (baseline to last treatment; P=.08). Conclusions: Patients with centrally mediated pain had the greatest drop in VAS scores. In contrast to patients with nociceptive pain due to a recurrent structural source, PNT potentially reversed the pain centralization process, resulting in activation of pain-signaling pathways only in the presence of noxious stimulation.

Poster 94: Percutaneous neuromodulation therapy for treatment of cervical spine pain patients with radiating shoulder and arm pain

Objective: To assess the efficacy of percutaneous neuromodulation therapy (PNT) for neck and upper-extremity pain. Design: Randomized controlled study. Setting: 7 outpatient pain treatment centers. Participants: 94 patients randomized to 2 treatment groups: PNT or no electric current PNT (NC-PNT). Subjects were further classified based on the presence or absence of persistent structural pathology: recurrent pain due to prominent structural and mechanical problems leading to nociceptive pain (eg, protrusion) or time-limited nonrecurrent injuries leading to centrally facilitated pain (eg, myofascial pain). Interventions: Patients received up to 8 weekly treatments, with 1-week and 1-month follow-ups after completion of the last treatment. Main Outcome Measures: 10-cm pain visual analog scale (VAS). Results: A multivariate analysis of variance revealed that a decrease in pain VAS scores was dependent on treatment received and type of pain ( P=.01). Within the PNT group, subjects with centrally facilitated pain experienced greater decreases ( P=.02) in VAS ratings compared with subjects with structural pathology (baseline, 6.3±1.9cm vs 6.3±1.4cm; 1wk post, 3.3±1.9cm vs 5.0±2.3cm; 1mo post, 4.0±2.0cm vs 5.6±2.0cm). Differences in VAS scores, within the NC-PNT group, were not related to diagnostic classification but to change from baseline ( P<.001) (baseline, 6.1±1.4cm; 1wk post, 4.6±2.6cm; 1mo post, 5.1±2.5cm). Conclusions: Central facilitation is an underlying mechanism for intractable pain in the cervical spine causing neck and upper-extremity pain. Results support the proposal that PNT reverses neuroplastic changes leading to centralization of pain. In the case of structural problems, persistent nociceptive input potentially limits analgesia obtained by modulation of the neural circuitry.

Long-term outcomes during treatment of chronic pain with intrathecal clonidine or clonidine/opioid combinations

To evaluate the effectiveness of intrathecal clonidine or clonidine/opioid admixture for the treatment of chronic pain states, a retrospective chart audit of 15 patients seen by the Pain Medicine and Neurosurgical Services was performed. Subjects included 9 men and 6 women aged 26–86 years. Diagnoses included complex regional pain syndrome, neuropathic pain, and cancer pain. All patients received a trial of single-shot and/or short-term infusion of clonidine. Those reporting a significant reduction in pain, or at least 50% reduction in their visual analog scale (VAS), received long-term therapy. Intrathecal clonidine as a single-shot dose, infusion, or as intrathecal polytherapy did not improve VAS scales from pre-treatment values in 5 patients. Ten patients reported significant pain relief or >50% decrease in VAS scores with the initial trial and received long-term therapy. Two received clonidine alone for 7–11 months before the therapy failed; others failed after just a few days. Seven of eight initially responded to clonidine alone (75–950 μg/day) before failing and requiring a second drug. Three received hydromorphone (200–8000 μg/day) and four morphine (0.15–15 mg/day) with clonidine. Four patients then failed 2-drug therapy (duration 6–21 months). Two continue with intrathecal clonidine/hydromorphone (duration 19–29 months) and 1 with clonidine/morphine (duration 21 months). After initiation of intrathecal clonidine, one patient reported good relief with clonidine/morphine until his death 5 months later. In this population, intrathecal clonidine was of limited utility for most patients. It may be of benefit for subset(s) of patients, but in our experience, duration of relief is typically <18 months.