Nonpharmacologic Modalities Research Articles

The effectiveness of music therapy for the treatment of Alzheimer's disease

Introduction: Alzheimer’s disease (AD) is a progressive neurodegenerative disorder and the most prevalent cause of dementia. It is caused by the degeneration of brain cells due to the accumulation of intracellular hyperphosphorylated tau - containing neurofibrillary tangles and extracellular plaques of amyloid-beta peptide. While pharmacotherapy remains the main form of treatment (including cholinesterase inhibitors and antagonists to NMDA), various non-pharmacological therapy modalities have gained increasing attention as complementary treatment options, such as music therapy. Purpose of the study: This review examines the role of music therapy as an important complement to baseline therapy for AD patients, focusing on indications, methods, and the prospect of music therapy. Materials and methods: A comprehensive literature review was conducted, analyzing 48 studies from the PubMed database (English-language, up to November 2024) that assess the efficacy, methods, and prospect of music therapy as an adjunctive therapy in Alzheimer’s disease. Conclusions: Music therapy is an established and effective supportive treatment for AD patients. It has demonstrated clinical success over many years as a tool for engaging multiple motor and sensory areas, shaping emotions, and evoking memories. This may be due to activating limbic and paralimbic structures, enhancing neuroplasticity, and modulating neurotransmitter systems. Despite the observable benefits of music therapy, the methodological limitations of existing studies highlight the need for further long-term research to standardize treatment approaches.

Osteopathic Manipulative Treatment: A Safe and Feasible Adjunct in Sickle Cell Disease Pain Management.

Children and adolescents and young adults (CAYAs) with sickle cell disease (SCD) suffer from recurrent acute pain episodes that result in hospitalization and confer substantial morbidity. Pharmacologic pain control is often inadequate, thus non-pharmacologic modalities are needed. Osteopathic manipulative treatment (OMT) is a potentially valuable non-pharmacologic addition to pain management. We describe eight patients hospitalized with SCD pain who received OMT. OMT was safe, feasible, and a promising adjunctive option for management of SCD pain.

Ketogenic diets therapy in the management of epileptic spasms syndrome.

Infantile Epileptic Spasm Syndrome (IESS) is a group of infantile spasm syndromes of various etiologies that typically present in early infancy, predispose to refractory epilepsy, and leave intellectual disability. Ketogenic diet therapy (KDT) is a non-pharmacologic treatment modality for medically refractory IESS. Recent scientific evidence supported the efficacy, safety, and tolerability of KDT for the treatment of IESS. KDT not only reduces the frequency of seizures in infants with IESS, but also improve their cognition and long-term prognosis. Recently, it has also received increasing attention as a potential treatment for neurological disorders. This reviewed the recent research progress of KDTs for the treatment of IESS, and discussed the different types and the mechanisms of KDTs, the expansion of KDT applications, the influencing factors, and future research issues.

Is It Possible to Combine Non-Invasive Brain Stimulation and Evidence-Based Psychosocial Interventions in Schizophrenia? A Critical Review.

In schizophrenia, it was suggested that an integrated and multimodal approach, combining pharmacological and non-pharmacological interventions, could improve functional outcomes and clinical features in patients living with schizophrenia (PLWS). Among these alternatives, evidence-based psychosocial interventions (EBPIs) and Non-Invasive Brain Stimulation (NIBS) represent feasible treatment options targeting the clinical features that are unmet needs of PLWS (especially negative and cognitive symptoms). As no clear evidence is available on the combination of these non-pharmacological approaches, this review aimed to collect the available literature on the combination of EBPIs and NIBS in the treatment of PLWS. We demonstrated that the field of combining EBPIs and NIBS in schizophrenia is in its infancy, as only 11 studies were reviewed. In fact, only a few trials, with divergent results, combined these non-pharmacological modalities; while emerging evidence is available on the combination of cognitive remediation and rTMS/iTBS, inconclusive results were obtained. Conversely, albeit preliminary, more solid findings are available on the combination of HF-rTMS and family intervention. Moreover, despite the fact that cognitive activation could not be considered an EBPI, promising results are available in combination with tDCS to improve the working memory domain. To overcome these limitations, we considered several methodological issues to promote research in this field.

Effect of Contrast Bath on Level of Neuropathic Pain among Patients with Type 2 Diabetes Mellitus

Diabetic neuropathy is a chronic sequela of DM and contrast bath is a non-pharmacological treatment modality which can reduce neuropathic pain among them. The present study was intended to assess the effect of contrast bath on level of neuropathic pain among patients with T2DM. The main objectives of the study were to assess the level of neuropathic pain among patients with T2DM, assess the effect of contrast bath on level of neuropathic pain and to determine the association between the neuropathic pain and socio demographic and clinical variables. The research approach was quantitative and the design adopted was quasi experimental. Sample consists of 60 patients with T2DM having neuropathic pain attending OPDs of Ananthapuri hospital selected by consecutive sampling technique. The conceptual framework adopted for the study was Wiedenbach’s Prescriptive theory. A structured interview schedule was used to collect socio demographic and clinical variables and Galer Neuropathy Pain Scale for assessing the neuropathic pain. Pre-test was done for both groups. After explanation and ensuring safety contrast bath was administered to experimental group for 20 minutes. Post-test was done by using the same tool for both experimental and control group. Mean, frequency, percentage were used to describe the data. Independent t test was used to assess the effect of contrast bath and association of level of neuropathic pain with socio demographic and clinical variables. The results revealed statistically significant (p<0.01) difference in the mean score of neuropathic pain in the experimental and control group after intervention. There was no significant association between level of neuropathic pain and socio demographic and clinical variables. The study infers that contrast bath is a simple non pharmacological home-based cost-effective intervention which can improve the daily functional abilities of patients with DM and thereby enhancing their quality of life.

Effect of Electrical Stimulation of Lingual Nerve on Xerostomia: A Randomized Controlled Trial.

Xerostomia is a subjective sensation of dry mouth affecting millions of people worldwide. Current management has limitations, often causing side effects. This study aims to investigate whether electrical stimulation of the lingual nerve could offer effective relief for xerostomia sufferers. Eligible participants were randomly assigned (1:1) to either the experimental or sham group, receiving electrical stimulation of the lingual nerve (n = 24) or sham stimulation (n = 23) for 12 wk. The primary outcome is the changes in xerostomia score using a 100-mm visual analog scale throughout the therapy. Participants assessed their dryness and assigned corresponding scores, with lower scores indicating more severe dry mouth. Secondary outcomes included remission rate in dry mouth frequency, changes in stimulated/unstimulated salivary flow rate (SSFR/USFR), and changes in Oral Health Impact Profile-14 (OHIP-14) questionnaire scores, where higher scores indicate greater impact on oral quality of life. At week 12, the electrical stimulation group showed greater improvement in xerostomia score compared to the sham group, with a mean between-group difference of 13.8 (95% confidence interval [CI], 10.0-17.6). The therapeutic effect of electrical stimulation was also confirmed by secondary outcomes. The remission rate of dry mouth was higher at 12 wk in the electrical stimulation group (61.9% [95% CI, 40.9%-79.3%] vs. 28.6% [95% CI, 13.8%-50.0%]). Participants in the electrical stimulation group also experienced a greater increase in USFR, with a mean difference of 14.5 (6.1-23.0) μL/min. Moreover, they exhibited significant improvement in OHIP-14 score after 12 wk of therapy, with a mean between-group difference of -10.0 (-13.9 to -6.2). No significant difference was observed between the 2 groups for SSFR (P = 0.702). Electric stimulation offers promise as a noninvasive, nonpharmacological strategy for the management of xerostomia. Further research is needed to understand its long-term effectiveness, optimal parameters, and underlying mechanisms. The study confirmed that electrical stimulation of the lingual nerve is a promising noninvasive and nonpharmacological modality for relief of xerostomia.

Cancer-Related Lymphedema and Psychological Distress.

Cancer-related lymphedema (CRL) places an already vulnerable patient population at risk for the development and worsening of psychological distress. The purpose of this review is to highlight factors contributing to distress in lymphedema secondary to breast, head and neck, genitourinary cancers, and melanoma and discuss pertinent treatment considerations. Multiple factors contribute to distress in CRL, including changes in body image, sleep, sexuality, functional capacity, and social interaction. There is limited literature describing psychopharmacological considerations in CRL, though exercise, which may be used for the treatment of depression and anxiety, may also improve CRL. Psychiatrists, oncologists, physiatrists, palliative medicine physicians, and physical and occupational therapists should have an awareness and understanding of CRL. To effectively manage distress in these patients, it is crucial to be mindful of psychotropic side-effect profiles, emphasize non-pharmacologic modalities including psychotherapy and exercise, and ensure patients receive evidence-based treatments for CRL.

Bridging the pain gap after cancer surgery - Evaluating the feasibility of transitional pain service to prevent persistent postsurgical pain - A systematic review and meta-analysis.

The lack of a dedicated pain service catering to the postsurgical period has resulted in the origination of the pain-period gap. This has led to a resurgence of transitional pain service (TPS). Our objective was to evaluate the feasibility of TPS in pain practice among postsurgical cancer patients and its prevention of persistent postsurgical pain (PPSP), culminating in chronic pain catastrophising. The protocol for this meta-analysis was registered in the International Prospective Register of Systematic Reviews (ID: CRD42023407190). This systematic review included articles involving all adult cancer patients undergoing cancer-related surgery experiencing pain, involving pharmacological, non-pharmacological and interventional pain modalities after an initial systematic pain assessment by pain care providers across diverse clinical specialities, targeting multimodal integrative pain management. Meta-analysis with meta-regression was conducted to analyse the feasibility of TPS with individual subgroup analysis and its relation to pain-related patient outcomes. Three hundred seventy-four articles were evaluated, of which 14 manuscripts were included in the meta-analysis. The lack of randomised controlled trials evaluating the efficacy of TPS in preventing PPSP and pain catastrophising led to the analysis of its feasibility by meta-regression. The estimate among study variances τ2 was determined and carried out along with multivariate subgroup analysis. A regression coefficient was attained to establish the correlation between the feasibility of TPS and its patient outcome measures and opioid-sparing. TPS interventions carried out by multidisciplinary teams incorporating bio-physical-psychological pain interventions have resulted in its successful implementation with improved pain-related patient outcomes mitigating the occurrence of PPSP.

Effects of Music on Pain and Anxiety During Otolaryngology Surgery: A Systematic Review and Meta-analysis.

Patients undergoing surgery commonly experience anxiety during their procedure which can negatively affect surgical outcomes. Music therapy has emerged as a promising noninvasive approach to reducing anxiety particularly in patients undergoing otolaryngology procedures.The objective of this study is to evaluate the effectiveness of music therapy on anxiety and pain during these procedures. PubMed and Embase. A systematic search was conducted using the PRISMA approach to retrieve articles published between 1980 and March 2024. The search terms were applied to PubMed and Embase databases. The search term yielded a total of 669 articles on PubMed and 1027 articles on Embase, 5 of which met the inclusion criteria. Five studies consisting of 4 randomized controlled trials and one case-control studies were included in our study, resulting in a total of 381 patients undergoing various otolaryngology procedures. Music therapy was found to reduce preoperative, perioperative, and postoperative anxiety and pain levels compared to control groups. Furthermore, patients who received music therapy experienced improvements in physiological parameters such as heart rate and blood pressure, indicating a positive impact on stress. Music therapy offers a potentially cost-effective and noninvasive method of reducing anxiety and pain in otolaryngological surgery patients. Our study indicates that music therapy can serve as a valuable addition to traditional pharmacological approaches in managing surgery-related anxiety and pain. However, more research is needed to standardize music therapy protocols and compare its effect in comparison to other nonpharmacologic and pharmacologic modalities to optimize care for patients.

Beyond Guideline-Directed MedicalTherapy: Nonpharmacologic Management for Patients With HeartFailure.

Heart failure (HF) is a leading cause of cardiovascular morbidity, mortality, and health care expenditure. Guideline-directed medical therapy and device-based therapy in HF are well established. However, the role of nonpharmacologic modalities to improve HF care remains underappreciated, is underused, and requires multimodal approaches to care. Diet,exercise and cardiac rehabilitation, sleep-disordered breathing, mood disorders, and substance use disorders are potential targets to reduce morbidity and improve function of patients with HF. Addressing these factors may improve symptoms and quality of life, reduce hospitalizations, and improve mortality in heart failure. This state-of-the-art reviewdiscusses dietary interventions, exercise programs, and the management of sleep-disordered breathing, mood disorders, and substance use in individuals with heart failure. The authors review the latest data and provide optimal lifestyle recommendations and recommended prescriptions for nonpharmacologic therapies.

The Nexus of Aging and Substance Use: A Scoping Review of Therapeutic Modalities for Geriatric Substance Use Disorders.

The insidious grip of substance use disorders (SUDs) manifests as a ubiquitous public health crisis, indiscriminately affecting individuals across the spectrum of age, gender, and socioeconomic status. While advancements in treatment offer a glimmer of hope, millions continue to grapple with the debilitating physical, psychological, and social consequences of addiction, particularly those involving alcohol and opioids. This crisis is further exacerbated by the alarming rise of SUDs among older adults. As the global population undergoes a process of demographic senescence, the escalating prevalence of SUDs in this demographic underscores the urgent need for nuanced interventions.This review explores the therapeutic landscape for managing SUDs in older adults, evaluating pharmacological and non-pharmacological treatment modalities.A detailed literature search was conducted using databases like PubMed, Google Scholar, and Scopus, and studies were selected based on their relevance to therapeutic interventions for older adults with SUDs, encompassing pharmacological and non-pharmacological modalities. The synthesized results provide an extensive overview of contemporary therapeutic approaches. The findings indicate that pharmacological interventions demonstrate varied effectiveness in managing opioid and alcohol use disorders, with each drug offering distinct benefits and limitations regarding safety, tolerability, and patient adherence. Non-pharmacological interventions provide critical psychological and social support, often requiring adaptations to meet elderly patients' needs effectively. Integrated care models, which combine pharmacological and non-pharmacological treatments, emerge as the most effective approach, addressing the comprehensive needs of elderly patients by leveraging multidisciplinary teams, centralized service access, and coordinated, patient-centered care. Implementing these models, however, requires overcoming significant resource and coordination challenges. Indeed, the confluence of a burgeoning geriatric population and escalating rates of SUDs necessitates the development and implementation of granular and integrated care protocols specifically designed for older adults. By employing such a targeted approach, optimism can be cultivated and the quality of life enhanced for this vulnerable and often overlooked segment of society. This ensures the fight against addiction extends its reach, leaving no one behind.

Diabetic Patients with Chronic Pain After Lumbar Surgery Experienced Fewer Analgesic Effects of Laser Therapy

Background: Recent studies indicate that several factors are associated with different responses to pain relief and alteration in reactions to non-pharmacological modalities and pharmacological medications. Biological processes appear to be contributory factors to these outcomes. Objectives: The purpose of this study is to examine how laser therapy can help as a conservative approach for chronic pain after back surgery in patients with diabetes mellitus (DM). Methods: This research included 22 diabetic patients and 26 non-diabetic patients with chronic pain after back surgery. Points of laser irradiation were determined by an ultrasound examination, specifically targeting bilateral sacroiliac joints, L2 - L3 through L5 - S1 facet joints, and the area of cluneal nerves. The duration of laser therapy was three weeks, with treatment sessions using an 808 nm diode laser at a power of 0.5W, performed every other day. Individuals were evaluated using the Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) before and after treatment, and again six months later. Results: Oswestry Disability Index and Numeric Rating Scale scores decreased significantly after treatment and six months later. Furthermore, analysis of the data showed that diabetic patients experienced less therapeutic effect during and after laser therapy sessions. Conclusions: Although laser therapy can reduce pain, diabetic patients reported a lower level of effectiveness compared to non-diabetic patients.

The Effectiveness of Virtual and Augmented Reality in Surgical Pain Management: A Systematic Review of Randomized Controlled Trials.

Satisfactory management of postoperative pain remains challenging. Nonpharmacological modalities such as virtual and augmented reality (VR/AR) offer potential benefits and are becoming increasingly popular. This systematic review evaluates the effectiveness and safety of VR/AR interventions on postoperative pain and recovery. MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL databases were searched from inception to July 27, 2023, for randomized controlled trials (RCTs), published in English, evaluating the use of VR/AR interventions for surgical pain relief. Study selection and data extraction were performed by pairs of reviewers independently and in duplicate, and potential risk of bias was determined using the Risk of Bias-version 2 (RoB 2) tool. Our outcomes included pain relief, reduction of anxiety, satisfaction, and adverse effects. Due to substantial heterogeneity, a narrative synthesis without meta-analysis was performed. We included 35 trials among 2257 citations, categorized as surgery (n = 12), minor procedures (n = 15), and postoperative physiotherapy (n = 8). Surgical group included various surgeries, with 11 using immersive VR predominantly in the postoperative period, and most reporting no differences in pain, but potential for reduced anxiety and sedation requirements. In the minor procedures group, most studies reported decreased pain and anxiety during the procedural performance. Two studies reported increased heart rate, while 2 others reported better hemodynamic stability. Home-based AR physiotherapy achieved (n = 6) similar pain and functional outcomes after knee replacement, with 1 large study (n = 306) reporting reduction of mean costs by $2745 for provision of 12 weeks physiotherapy. There were some concerns around potential bias for most studies, as the nature of interventions make it challenging to blind assessors and participants. No important adverse effects were noted using VR/AR technology. Evidence from RCTs indicates that the use of immersive VR during minor procedures may reduce procedural pain, decrease anxiety, and improve satisfaction. However, small studies, inconsistent effect, and variation in the application of interventions are important limitations. Evidence to support the application of AR/VR for major surgeries is limited and needs to be further investigated. Use of home-based physiotherapy with AR likely has economic advantages, and facilitates virtual care for appropriate patients who can access and use the technology safely.

High-Intensity Laser Therapy in Pain Management of Knee Osteoarthritis.

Knee osteoarthritis (KO) is an important health condition, affecting one third of people aged 65 years or more. Pain is the main cause of disability. Pain management in KO includes pharmacological and non-pharmacological modalities. Patient education, lifestyle changes, physical exercise, and physical agents are prescribed as a first approach for pain control. Laser therapy is part of many therapeutical protocols, with two forms: low-level laser therapy (LLLT) and high-intensity laser therapy (HILT). This paper aimed to stress the advantages of HILT based on a greater wavelength, higher energy delivery, and deeper tissue penetration. Research on 23 published trials revealed that the analgesic effect is rapid, cumulative, and long lasting. Compared to sham, to LLLT, or to other combinations of therapeutical modalities, HILT provided significantly better results on pain reduction and functional improvement. Ultrasound examination showed a reduction in intra-articular inflammation.

Liver cirrhosis: current status and treatment options using western or traditional Chinese medicine.

Liver cirrhosis arises from liver fibrosis and necroinflammation caused by various mechanisms of hepatic injury. It is a prevalent condition in clinical practice characterized by hepatocellular dysfunction, portal hypertension, and associated complications. Despite its common occurrence, the etiology and pathogenesis of liver cirrhosis remain incompletely understood, posing a significant health threat. Effective prevention of its onset and progression is paramount in medical research. Symptoms often include discomfort in the liver area, while complications such as sarcopenia, hepatic encephalopathy, ascites, upper gastrointestinal bleeding, and infection can arise. While the efficacy of Western medicine in treating liver cirrhosis is uncertain, Chinese medicine offers distinct advantages. This review explores advancements in liver cirrhosis treatment encompassing non-pharmacological and pharmacological modalities. Chinese medicine interventions, including Chinese medicine decoctions, Chinese patent medicines, and acupuncture, exhibit notable efficacy in cirrhosis reversal and offer improved prognoses. Nowadays, the combination of Chinese and Western medicine in the treatment of liver cirrhosis also has considerable advantages, which is worthy of further research and clinical promotion. Standardized treatment protocols based on these findings hold significant clinical implications.

Improvement of the Cognitive Abilities in a Chronic Generalized Anxiety Disorder and Moderate Depression Case using a Novel Integrated Approach: The Cognitome Program

Cognitive impairment has been increasingly observed among patients with anxiety disorders and major depressive disorders impacting their normal daily functioning as well as quality of life. A multitude of evidence suggests that the most affected cognitive abilities are memory, attention, perception, and executive functioning in patients with anxiety and depression. Impairment in these higher-order cognitive functions can be attributed to age, education, diet, hormonal changes, stress, and prolonged use of drugs/alcohol/ medicines. To address the issues related to cognitive impairment various non-pharmacological therapeutic modalities such as Cognitive remediation approaches viz; cognitive rehabilitation, cognitive stimulation, and cognitive training; Audio-visual entrainment; mindfulness-based interventions; and neurofeedback have come into play in recent years. It is imperative to understand that the ability to test, measure, and monitor cognitive performance along with implementing cognitive remediation approaches viz; cognitive stimulation, cognitive training, etc. across the lifespan helps in early identification, accessing treatments faster, staying healthy for longer, and improving overall quality of life. This article discusses a case study of a client suffering from generalized anxiety disorder and moderate depression who after undergoing and following a novel therapeutic approach, ‘The Cognitome Program’ has shown credible improvement in cognitive abilities, along with a prominent reduction in the symptoms of anxiety, depression, and better psychological and physical well-being. Guided by the concept of neuroplasticity and cognitive plasticity, our innovative neuroscientific holistic program- ‘The Cognitome Program’ empowers unlocking hidden cognitive potential using cutting-edge methodologies and personalized strategies.

The Tandem VR™ protocol: Synchronized nature-based and other outdoor experiences in virtual reality for hospice patients and their caregivers

BackgroundNature-based and other outdoor virtual reality (VR) experiences in head-mounted displays (HMDs) offer powerful, non-pharmacological tools for hospice teams to help patients undergoing end-of-life (EOL) transitions. However, the psychological distress of the patient-caregiver dyad is interconnected and highlights the interdependence and responsiveness to distress as a unit. Hospice care services and healthcare need strategies to help patients and informal caregivers with EOL transitions. MethodsOur study uses the synchronized Tandem VRTM approach where patient-caregiver dyads experience immersive nature-based and other outdoor VR content. This mixed methods study will recruit 20 patient-caregiver dyads (N = 40) enrolled in home hospice services nearing EOL. Dyads will experience a personalized nature-based and other outdoor VR experience lasting 5–15 min. Self-reported questionnaires and semi-structured interviews will be collected pre/post the VR intervention to identify the impacts of Tandem VRTM experiences on the QOL, pain, and fear of death in patient-caregiver dyads enrolled with hospice services. Additionally, this protocol will determine the acceptance of Tandem VRTM experiences by dyads as a non-pharmacological modality for addressing patient and caregiver needs. Acceptance will be quantified by the number of dyads accepting or declining the VR experience during recruitment. DiscussionUsing personalized, nature-based and other outdoor VR content, the patient-caregiver dyads can simultaneously engage in an immersive encounter may help alleviate symptoms associated with declining health and EOL phases for the patient and the often overburdened caregiver. This protocol focuses on meeting the need for person-centered, non-pharmacological interventions to reduce physical, psychological, and spiritual distress. Trial registrationNCT06186960.

Effectiveness of aromatherapy in reduction of dental anxiety in pediatric dental patients: A systematic review

In recent years, various researchers have attempted to utilize Aromatherapy for allaying dental anxiety in pediatric patients. The present systematic review aims to comprehend the efficacy of aromatherapy in reducing dental anxiety in pediatric patients, exploring different aromatherapy agents, dispersion methods, and their anxiety-relieving capacities. A systematic search was performed in the following databases: MEDLINE (Ovid), Pubmed, Pubmed Central, Web of Science Citation Index Expanded (SCIEXPANDED), and Google Scholar using the key terms “Aromatherapy” AND “Pediatric” OR “Children” AND “Dental Anxiety” OR “Fear” to identify articles published in the English language without any restriction for the time of publication. A total of nine randomized controlled trials were identified that assessed various essential oils such as lavender, orange, and lemongrass for aromatherapy in pediatric patients during dental treatment. Most of these studies employed aromatherapy using a diffuser during non-pain-promoting dental treatments in children of 6 to 9 years of age. Aromatherapy is an effective non-pharmacological and non-invasive modality for reducing dental anxiety in pediatric patients which is free of adverse effects. However, there's a need for standardized methods of dispersion and clearer guidelines for oil posology

Emergent Management of Status Epilepticus.

Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.

Fatigue: Pharmacological and non-pharmacological management in patients with multiple sclerosis

Multiple sclerosis (MS) is a neurological disease that causes inflammation and demyelination of the central nervous system. It progresses with episodic attacks and is particularly disabling in young adults. Among the many symptoms experienced by MS patients, fatigue is one of the most commonly reported. Approximately 75 – 90% of patients experience fatigue, with the vast majority reporting it as one of their top three symptoms. Over half of MS patients find fatigue to be a debilitating symptom that interferes with their work, family, and social life, significantly affecting their overall quality of life. Despite its prevalence, fatigue is often overlooked due to its subjective nature. Although the pathophysiology of fatigue is not fully understood, it has been associated with various variables such as stress, vigorous exercise, anxiety, depression, insomnia, pain, spasticity, medication side effects, anemia, and temperature elevation. Effective management of multifactorial fatigue requires a multidisciplinary approach, incorporating both pharmacological and non-pharmacological modalities. An analysis of studies conducted over the last decade indicates that the efficacy of pharmacological methods is controversial, with a high side effect profile. Among non-pharmacological methods, exercise has proven to be one of the most effective interventions. In addition, dietary modifications and vitamin supplementation have demonstrated effectiveness. Cognitive behavioral therapy, acupressure, acupuncture, the application of cooling garments, transcranial stimulation, web-based education and counseling, and guided imagery have also reported positive results. However, further studies with larger sample sizes are necessary to objectively evaluate their effectiveness. In conclusion, fatigue is a prevalent symptom among MS patients. While the management of fatigue through pharmacological methods remains controversial, non-pharmacological methods have demonstrated effectiveness, are low-cost, and have no side effects.