Experienced Pain Relief Research Articles

Initial clinical experience with surface image guided (SIG) radiosurgery for trigeminal neuralgia

Background: To evaluate the initial clinical experience with a surface image guided technique for stereotactic radiosurgery using minimal patient immobilization and real-time patient motion monitoring for the treatment of trigeminal neuralgia (TN). Methods: The study describes the first seven TN patients treated with this technique. Head positioning was achieved with a patient-specific head mold made out of expandable foam that conforms to the patient’s occiput. The face of each patient was left open and unobstructed for maximal comfort. The motion of a region of interest consisting of the forehead, eyes, nose, and temporal bones was monitored during treatment using a video surface imaging system (Vision RT Ltd., London, UK). Initial setup of the patient was performed with the surface imaging system using the treatment planning computed tomographic (CT) scan. Initial setup was confirmed and finalized with cone-beam CT (CBCT) and KV X-ray images prior to treatment. The dedicated linear accelerator used for delivery was a Trilogy (Varian Medical Systems, Palo Alto, CA) with 5 mm collimator with 13 arcs. Patients were monitored during treatment with surface imaging cameras and software, equipped with a beam stop mechanism if the patient’s motion was found to exceed a specified tolerance. Results: Seven patients with TN underwent single fraction radiosurgery to a dose range of 80-90 Gy with surface image guidance. All patients experienced pain relief. Four of the seven patients experienced complete resolution of pain. At a median follow-up of 31.4 months, two of seven patients developed pain recurrence. One patient reported intermittent facial numbness after SRS which resolved by 9 months post-treatment. Conclusions: The surface image guided technique using minimal immobilization and real time surface imaging has proven to be safe and effective in a small cohort of patients with TN. To our knowledge this is the first series describing the use of this technology in SRS for TN. Patient compliance is important, and appears improve given the speed and comfort of this technique. An additional degree of semi-rigid immobilization may be required in some patients.

Efficacy and safety of ultrasound-guided saphenous nerve block in patients with chronic knee pain

IntroductionKnee osteoarthritis is a common cause for consultation around the world. Many patients with mild symptoms respond to conservative treatment, while others require interventional therapy including peripheral nerve blocks. ObjectiveTo establish the clinical efficacy and safety of interventional management with ultrasound-guided saphenous nerve block in patients with chronic keen pain. Materials and methodsDescriptive, retrospective trial in chronic keen pain patients who underwent ultrasound-guided interventional therapy at the pain clinic in the country, between September 2011 and June 2012, to determine the clinical efficacy and safety of the procedure. Data were obtained from all patients prior to the procedure, and then at two days, one month and three months later. The pain intensity was measured using the visual analog scale. Results25 saphenous nerve blocks were performed. 68% of the patients experienced pain relief within two days. 56% and 40% exhibited relief one and three months after the procedure, respectively, with a statistically significant difference (p<0.0001) between the baseline visual analog scale and the follow-up evaluation. Patients with a history of fibromyalgia, neuropathic characteristics and previous knee surgery exhibited variable analgesic responses to the procedure. ConclusionsInterventionist chronic knee pain management with ultrasound-guided saphenous nerve block was an effective and safe approach for these patients.

PARE0003 The Effect of Exercising in Warm Water – Seen from the Perspective of the Patients

BackgroundIn Denmark one in eight of the population, has one or more rheumatic diseases causing pain and decreased physical function in everyday life.Exercising in warm water pools has become a...

Eficacia y seguridad del bloqueo del nervio safeno guiado por ultrasonido en pacientes con dolor crónico de rodilla

IntroductionKnee osteoarthritis is a common cause for consultation around the world. Many patients with mild symptoms respond to conservative treatment, while others require interventional therapy including peripheral nerve blocks. ObjectiveTo establish the clinical efficacy and safety of interventional management with ultrasound-guided saphenous nerve block in patients with chronic keen pain. Materials and methodsDescriptive, retrospective trial in chronic keen pain patients who underwent ultrasound-guided interventional therapy at the pain clinic in the country, between September 2011 and June 2012, to determine the clinical efficacy and safety of the procedure. Data were obtained from all patients prior to the procedure, and then at two days, one month and three months later. The pain intensity was measured using the visual analog scale. Results25 saphenous nerve blocks were performed. 68% of the patients experienced pain relief within two days. 56% and 40% exhibited relief one and three months after the procedure, respectively, with a statistically significant difference (p < 0.0001) between the baseline visual analog scale and the follow-up evaluation. Patients with a history of fibromyalgia, neuropathic characteristics and previous knee surgery exhibited variable analgesic responses to the procedure. ConclusionsInterventionist chronic knee pain management with ultrasound-guided saphenous nerve block was an effective and safe approach for these patients.

Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.

The relationship between pain and eating among overweight and obese individuals with osteoarthritis: an ecological momentary study.

Osteoarthritis (OA) patients who are overweight or obese report higher levels of pain compared with their normal-weight OA counterparts. Evidence suggests that overweight or obese OA patients also experience pain relief from eating foods high in calories, fat or sugar. Eating to alleviate pain may be problematic because it can lead to additional weight gain, which may contribute to heightened pain. To investigate the relationship between pain and food intake using ecological momentary assessments in a sample of 71 overweight and obese OA patients. Participants completed two consecutive days of diary entries in which they recorded their levels of pain, mood and food intake throughout the day. Data were analyzed using generalized estimating equations that modelled pain as a predictor of calorie, fat and sugar intake. All models were adjusted for sex, body mass index, negative mood, time and treatment history. Pain significantly predicted calorie (Z=2.57; P=0.01) and fat intake (Z=1.99; P=0.05). Using ecological momentary assessments as a novel approach, the present study provides preliminary data supporting a relationship between pain and food intake among overweight and obese OA patients. Continued advances in our understanding of the relationship between pain and eating behaviour may help to optimize intervention strategies for these patients.

Erratum to “Addition of Metanx in Pregabalin Partial Responders for Painful Diabetic Neuropathy”

Objective: To study the effect of addition of Metanx on burning parasthesias in patients with symptomatic diabetic neuropathy who had obtained only partial symptom resolution with pregabalin. Research design and methods: This was an open-label pilot study. There were 16 patients (7 males, 9 females) in the study group and 8 patients (3 males, 5 females) in the control group. A patient numeric rating scale (0 - 10) of neuropathy associated pain was obtained at baseline and at 20 weeks. The control group continued on a fixed dosage of pregabalin without additional medication, while the study group was supplemented with Metanx (a proprietary blend of bioactive B-vitamins), in addition to being continued on a fixed dosage of pregabalin. Results: After 20 weeks, significantly more patients in the study group experienced pain relief compared to the control group (87.5% vs. 12.5%, respectively, p =0.005). The average pain score reduction after 20 weeks in the study group was 3 compared to0.25 inthe control group (p may be used for the relief of pain in patients that have obtained only partial resolution of symptomatology from pregabalin.

Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty

Glenoid bone grafting can be useful to restore an asymmetrically eroded glenoid to better support the glenoid component and improve positioning. The purpose of this study was to evaluate the clinical and radiographic results of patients undergoing structural bone grafting for glenoid deficiency with placement of a cemented glenoid component during primary total shoulder arthroplasty. Between January 1, 1976, and December 31, 2008, 24 patients (25 shoulders) of 2607 shoulders undergoing primary total shoulder arthroplasty (0.96%) had structural bone grafting with a humeral head autograft and screw fixation. The mean clinical follow-up was 8.7 years, and the mean radiographic follow-up was 7.6 years. Twenty-three shoulders experienced pain relief, and patients expressed satisfaction with the operation in these shoulders. Postoperative active elevation averaged 148°, and external rotation with the arm at the side averaged 60°. On radiographic evaluation, 10 shoulders had glenoids at risk for component loosening. Two of these shoulders were symptomatic and underwent revision surgery to address glenoid component loosening. The Neer result rating was excellent in 18 shoulders, satisfactory in 5, and unsatisfactory in the 2 shoulders undergoing revision. Structural bone grafting in primary total shoulder arthroplasty is uncommonly necessary. When it is performed, the clinical outcomes are favorable; however, radiographic analysis shows a moderate rate of failure of glenoid component fixation. It seems likely that alternative treatment methods may prove to be more effective in addressing glenoid wear.

ACUPUNCTURE IS AN EFFECTIVE TREATMENT FOR PAIN AND OTHER MS SYMPTOMS

IntroductionComplementary therapies are often sought by patients with MS despite a lack of available efficacy data. Acupuncture is one such therapy provided in Tayside through a nurse led service. We...

Palliative embolization for osteosarcoma

The prognosis of patients with metastatic, recurrent, and/or unresectable osteosarcoma is poor. Aggressive local and medical treatments are available for palliation. Palliative treatments include isolated limb perfusion, radiation therapy, embolization, chemoembolization, thermal ablation, and cryoablation. Their aim is pain relief and tumor size reduction with minimum complications. We present 19 patients with metastatic, recurrent, and/or unresectable osteosarcoma of the pelvis and lower lumbar spine treated with palliative selective embolization using N-2-butyl cyanoacrylate. All patients had chemotherapy. At the time of embolization, they experienced severe pain refractory to analgesics. Diagnostic angiography was performed pre-embolization to determine the vascular mapping and hemodynamic status of the tumor. Post-embolization angiography was done to evaluate for complete occlusion of the pathological vessels. Mean follow-up was 18 months. Local pain, tumor necrosis and size, and complications were recorded. In all patients, pre-embolization angiography showed hypervascularity of the tumor from extensive neovascularization. Five patients had repeat embolization. All patients experienced pain relief at a mean of 3 days post-embolization. No patient had recurrent pain with the intensity of that before embolization. Variable tumor necrosis was observed in follow-up imaging, and reduction in tumor size was minimum. All patients experienced pain at the site of embolization, which resolved completely 1-5 days after embolization. Four patients with pelvic osteosarcomas experienced paraesthesias at the distribution of the sciatic nerve. Selective arterial embolization is a useful local palliative treatment for patients with advanced osteosarcoma for pain relief.

S1-1. Spinal cord stimulation for post-stroke pain

Spinal cord stimulation (SCS) is used to treat for several types of intractable pain syndromes, but it is not commonly used for treating post-stroke pain. Therefore, in this study, we analyzed the effects of SCS in patients with post-stroke pain. Neurological imaging and pharmacological analysis using thiopental, ketamine and morphine tests were conducted for 30 patients with post-stroke pain. For all patients, percutaneous electrodes were inserted under local anesthesia, and trial stimulation was performed for 5–7 days. If the patient experienced pain relief during the trial stimulation, a pulse generator was implanted. Of the 30 patients, 26 (87%) experienced satisfactory pain relief and underwent implantation. Ten patients received dual-octad lead SCS. The stimulation induced adequate paresthesia in all 10 patients. Nine (90%) of the 10 patients experienced satisfactory pain relief and opted for pulse generator implantation in order to proceed with the treatment. Upper cervical SCS was performed for patients with pain in not only the upper and lower extremities but also the face. Upper cervical SCS provided good paresthesia coverage and was effective for such patients. We think that patients with post-stroke pain may respond favorably to dual-octad lead SCS, and advancements in devices for SCS would further improve treatment outcomes for such patients.

Health-related quality of life in persons with long-term neck pain after treatment with qigong and exercise therapy respectively

The aims of this study were to evaluate health-related quality of life (HRQoL) in individuals with long-term, non-specific neck pain before and after treatment with qigong versus exercise therapy and to compare their HRQoL with an age and sex-matched reference population. A total of 122 persons were randomly assigned to either qigong or exercise therapy. HRQoL was measured with the 36-item Short Form Health Survey (SF-36) and pain intensity was assessed with a visual analogue scale (VAS) before and immediately after treatment, and at 12-month follow-up. Both treatment groups improved on all subscales; however, no differences were observed between the treatment groups either before or after treatment. Those who experienced pain relief (at least 10 mm change on VAS; 53%) also significantly improved from baseline on all SF-36 subscales. Persons with chronic neck pain had significantly lower scores on all SF-36 subscales than normative reference values both before and after treatment. The results of this study indicate no differences between qigong and exercise therapy in HRQoL outcome; however, broad HRQoL improvements seem to be contingent on significant pain reduction. As pain reduction was achieved in roughly half of the study group, more work is needed to refine these therapies, to identify neck pain persons most likely to benefit from them and to develop other physiotherapy treatment strategies suitable to non-responders.

Earthquake generated proximal tibial nerve compression treated by surgery

This article reports on nine cases of proximal tibial nerve compression by the soleal tendinous arch caused by unsuitable treatment of acute compartment syndrome (ACS). Also, we report the clinical results of neurolysis and analyse the cause of this special type of neurological compression. There were nine extremities in nine patients included in the study. All patients were among the victims of the Wenchuan earthquake in 2008. All patients had a previous lower extremity ACS. Pain level, numbness in the sole, muscle strength of the flexor hallucis longus and Tinel's sign were evaluated pre- and post-operatively. Each proximal tibial nerve compression was subjected to neurolysis with division of the soleal tendinous arch. At a mean follow-up of 22 months, eight patients (87 %) with weakness of the flexor hallucis longus showed improvement in flexor strength and seven patients (78 %) exhibited improved sensory function in the sole. All patients experienced pain relief. Subjective pain was reduced from an average score of 2.7 to 0.7 based on a visual analogue scale. Physical examination for Tinel's sign revealed all patients experienced relief of radiating pain, but two patients still retained a positive Tinel's sign (mild) over the soleal tendinous arch. In summary, four patients were highly satisfied, four were satisfied and one was neither satisfied nor dissatisfied with functional recovery after neurolysis. Unsuitable treatment of lower extremity ACS can lead to tibial nerve compression beneath the soleal tendinous arch. Neurolysis may improve pain and sensory and motor function.

Duloxetine use in chronic painful conditions – individual patient data responder analysis

BackgroundDuloxetine has been studied in four distinct chronic pain conditions – osteoarthritis (OA), fibromyalgia, chronic low back pain (CLBP) and diabetic peripheral neuropathic pain (DPNP). These trials have involved large numbers of patients with at least moderate pain, and have used similar methods for recording pain intensity, over about 12 weeks.MethodsData from the trials were pooled according to painful condition, and reanalysed at the level of the individual patient and using increasing levels of pain intensity reduction (<15%, 15–29%, 30–49%, ≥50%), with different imputation methods on withdrawal.ResultsThe proportion of patients recording at least 50% pain intensity reduction plateaued after 2–6 weeks in fibromyalgia, and 8–12 weeks in other conditions. The duloxetine-specific benefit [number needed to treat (NNT) for at least 50% pain intensity reduction] was fairly constant after about 2 weeks for DPNP and fibromyalgia and after about 4 or 5 weeks for OA and CLBP. In all conditions, responses were bimodal, with patients generally experiencing either very good or very poor pain relief. Last-observation-carried-forward imputation produced numerically and occasionally statistically better (lower) NNTs than use of baseline-observation-carried-forward (true response).ConclusionsBaseline-observation-carried-forward (true response), which combines the success of high levels of pain relief with the failure to experience pain relief on withdrawal of the drug is conservative and probably reflective of clinical practice experience. The distribution of effect was not normal; few patients had the average response and averages are not an appropriate descriptor for these data.What's already known about this topic?Last-observation-carried-forward (LOCF) imputation overestimates efficacy when adverse event withdrawals are high.Previous analyses of duloxetine in four chronic pain conditions reported mainly average pain changes using LOCF imputation.What does this study add?Responses were bimodal: patients generally experienced very good or very poor pain relief. Last-observation-carried-forward results were numerically lower (better) than true responder.Duloxetine was an effective analgesic in all four chronic pain conditions using highest level of evidence.

Sacral radiculopathy due to cement leakage from percutaneous sacroplasty, successfully treated with surgical decompression

Percutaneous sacroplasty is a procedure adapted from vertebroplasty, which is designed to ameliorate the painful morbidity associated with sacral insufficiency fractures without the invasiveness of open surgery. Early estimates of efficacy, according to several case reports and small series, appear promising, but the procedure is not without risk. Several cases of radiculopathy due to nerve root compression by extravasated polymethylmethacrylate (PMMA) have been reported. The authors present a case of radiculopathy caused by cement leakage from sacroplasty, treated with surgical decompression of the compromised nerve root. The patient presented with left S-1 radiculopathy and was found on CT to have a left S-1 nerve root completely encased in PMMA over a portion of its length. The patient underwent sacral laminectomy with the removal of PMMA and experienced pain relief and the return of function postoperatively. Surgical removal of PMMA extravasated during sacroplasty is feasible and should be considered when nerve root compression or canal stenosis causes pain or neurological deficit refractory to conservative therapy.

Proximal direct endarterectomy combined with simultaneous distal endovascular therapy for chronic full-length occlusion of the superficial femoral artery in elderly patients

The most proximal ostial site of the chronic occlusive superficial femoral artery is not suitable for ballooning or stenting because the deep femoral artery may be occluded by these procedures. Thus, the feasibility of performing an open endarterectomy for the occluded ostium of the superficial femoral arteries combined with an endovascular therapy for the remaining distal site was evaluated. Eleven critically ischemic limbs in 10 elderly patients with poor general health were enrolled. They had full-length occlusion of the superficial femoral artery involving its ostium. The ostial site was managed with an open endarterectomy followed by endovascular therapy for the remaining distal site. All procedures were successfully performed. All patients experienced pain relief, and the wounds healed. During the follow-up observation period (average: 23.9 ± 14.7 months), nine patients died. None of the patients, including those who had lost patency of the superficial femoral artery, received major amputation. Elderly patients, including those who were in terminal stage, were able to withstand the operation, and their postoperative quality of life was not compromised. Although the patency following the surgery was limited, sparing the deep femoral artery could either prevent or delay the recurrence of critical limb ischemia.

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period

Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative births (ventouse or forceps assisted births). To determine the efficacy of a single administration of paracetamol (acetaminophen) systemic drugs used in the relief of acute postpartum perineal pain We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 6 November 2012. Randomised controlled trials (RCTs) assessing paracetamol (acetaminophen) in a single dose compared with placebo for women with early postpartum perineal pain. We excluded quasi-RCTs and cross-over studies. Two review authors assessed each paper for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. We did not identify any new trials from the updated search so the results remain unchanged as follows.We have included 10 studies describing two dosages of paracetamol. Of these, five studies (526 women) assessed 500 mg to 650 mg and six studies (841 women) assessed 1000 mg of paracetamol. We chose to use random-effects meta-analyses because of the heterogeneity in dosage used. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context.More women experienced pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89, 10 studies, 1279 women). In addition, there were significantly fewer women having additional pain relief with paracetamol compared with placebo (RR 0.34, 95% CI 0.21 to 0.55, eight studies, 1132 women). Both the 500 mg to 650 mg and 1000 mg doses were effective in providing more pain relief than placebo.Maternal and neonatal potential adverse drug effects were not assessed in any of the included studies. Indeed few secondary outcomes were assessed. More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.

Posterior Talar Intraosseous Ganglion Treated with Arthroscopic Debridement, Microfracture and Injectable Bone Graft Substitute

We report the case of a 57 year old female patient presenting with longstanding diffuse ankle pain. SPECT-CT was useful in making the diagnosis of an intraosseous ganglion of the posterior talus. The patient was treated with posterior arthroscopic debridement of the cyst via a two portal approach and grafting with an injectable synthetic bone graft substitute (PRO-DENSE®). The patient experienced rapid relief of pain and made a quick recovery. The surgical technique is discussed as well as a review of the current literature.

Prolotherapy: A Non-Invasive Approach to Lesions of the Glenoid Labrum; A Non-Controlled Questionnaire Based Study

Lesions of the glenoid labrum are a common cause of shoulder instability and a frequent finding in patients with shoulder pain. Management of these patients typically involves an attempt to avoid surgery through conservative treatment. However, there is currently a dearth of conservative options that promote labral healing. Regenerative injection therapies, including prolotherapy, have shown promise in the treatment of several musculoskeletal disorders, but have not previously been applied to glenoid labral tear. Here we review several important aspects of these lesions and present an initial case series of 33 patients with labral tear that were treated in our clinic with intra-articular injections of hypertonic dextrose. Patient-reported assessments were collected by questionnaire at a mean follow-up time of 16 months. Treated patients reported highly significant improvements with respect to pain, stiffness, range of motion, crunching, exercise and need for medication. All 31 patients who reported pain at baseline experienced pain relief, and all 31 who reported exercise impairment at baseline reported improved exercise capability. Patients reported complete relief of 69% of recorded symptoms. One patient reported worsening of some symptoms. Prolotherapy for glenoid labral tear appears to be a safe procedure that merits further investigation.

Bilateral Tarsal Coalition in a National Collegiate Athletic Association Division I Basketball Player: A Case Report

To present a case of bilateral subtalar joint coalition in a National Collegiate Athletic Association Division I basketball player and the treatment plan that was used to manage the coalition from the beginning of conference play through the postseason. A 20-year-old male basketball athlete (height = 182.8 cm, mass = 83.4 kg) presented with bilateral subtalar joint tarsal coalition that became symptomatic in 2006 and resulted in constant pain with any form of activity. Traumatic injury of the talocalcaneal joint. Nonsurgical intervention of conservative therapy was elected. Less than 13% of the overall population is affected with tarsal coalition, so it is safe to assume that very few athletes competing at the collegiate or elite level suffer from this condition. This is the first report in the literature to document conservative manual therapies used to manage the symptoms of subtalar joint tarsal coalition in a Division I basketball player. After the intensive treatment program for tarsal coalition was implemented, the patient experienced pain relief and was able to continue to compete at a competitive level. This case represents the need to further explore and document a conservative treatment protocol for tarsal coalition.