Refractory Chronic Pain Research Articles

Sexual Dysfunction in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome: Improvement After Trigger Point Release and Paradoxical Relaxation Training

The impact of chronic pelvic pain syndrome on sexual function in men is underestimated. We quantified sexual dysfunction (ejaculatory pain, decreased libido, erectile dysfunction and ejaculatory difficulties) in men with chronic pelvic pain syndrome and assessed the effects of pelvic muscle trigger point release concomitant with paradoxical relaxation training. We treated 146 men with a mean age of 42 years who had had refractory chronic pelvic pain syndrome for at least 1 month with trigger point release/paradoxical relaxation training to release trigger points in the pelvic floor musculature. The Pelvic Pain Symptom Survey and National Institutes of Health-Chronic Prostatitis Symptom Index were used to document the severity/frequency of pain, urinary and sexual symptoms. A global response assessment was done to record patient perceptions of overall therapeutic effects at an average 5-month followup. At baseline 133 men (92%) had sexual dysfunction, including ejaculatory pain in 56%, decreased libido in 66%, and erectile and ejaculatory dysfunction in 31%. After trigger point release/paradoxical relaxation training specific Pelvic Pain Symptom Survey sexual symptoms improved an average of 77% to 87% in responders, that is greater than 50% improvement. Overall a global response assessment of markedly or moderately improved, indicating clinical success, was reported by 70% of patients who had a significant decrease of 9 (35%) and 7 points (26%) on the National Institutes of Health-Chronic Prostatitis Symptom Index (p < 0.001). Pelvic Pain Symptom Survey sexual scores improved 43% with a markedly improved global response assessment (p < 0.001) but only 10% with moderate improvement (p = 0.96). Sexual dysfunction is common in men with refractory chronic pelvic pain syndrome but it is unexpected in the mid fifth decade of life. Application of the trigger point release/paradoxical relaxation training protocol was associated with significant improvement in pelvic pain, urinary symptoms, libido, ejaculatory pain, and erectile and ejaculatory dysfunction.

Treatment of Chronic Low Back Pain With Successive Injections of Botulinum Toxin A Over 6 Months

The aim of this study was to evaluate the effects of two successive neurotoxin treatments for chronic low back pain using multiple pain rating scales in an open-label, prospective study. Adult patients with chronic low back pain received multiple paraspinal muscle injections with a maximum dosing of 500 units of botulinum A toxin per session. Those with a beneficial clinical response received a second treatment at 4 months. Pain was assessed by visual analog scale (VAS), modified low back pain questionnaire (OLBPQ), and a clinical low back pain questionnaire (CLBPQ) at baseline, 3 weeks, 2 months, 4 months, and 6 months after the first treatment. Eighteen women and 42 men, ages 21 to 79 years (mean 46.6 years), with low back pain of a mean duration of 9.1 years were included. Significant improvement in back and radicular pain occurred at 3 weeks in 60% and at 2 months in 58% of the cohort. Beneficial clinical response to the first injection predicted response to reinjection in 94%. A significant minority of patients had a sustained beneficial effect from the first injection at 4 (16.6%) and 6 months (8.3%). Two patients had a transient flu-like reaction after the initial treatment. Botulinum toxin A improves refractory chronic low back pain with a low incidence of side effects. The beneficial clinical response is sustained with a second treatment.

Neuropsychologic aspects of post-traumatic headache and chronic daily headache

The management of patients with chronic refractory head pain remains a treatment challenge. Treatment focus should be multidisciplinary as patients evolve into a deteriorated status with psychologic, social, vocational, and cognitive dysfunction. The neuropsychologist will gather premorbid and comorbid information, assess cognitive functioning, and be involved in every behavioral medicine and treatment decision. The patient with post-traumatic head pain copes with head injury sequelae. Issues related to worker's compensation, insurance, disability decisions, and litigation are intrinsic to these patient groups.

Effectiveness of a Multidisciplinary Chronic Pain Program for Treatment of Refractory Patients with Complicated Chronic Pain Syndromes

Interventional pain physicians commonly encounter patients with a treatment refractory "chronic pain syndrome". Such patients have a chronically painful medical disorder that is complicated by a number of psychosocial factors, including psychiatric and substance use disorders, physical deconditioning, dependency upon the healthcare system, and perceived impairments that are out of proportion to objective medical findings. The objective of the following study was to determine the effectiveness of a multidisciplinary chronic pain program for adult patients with treatment refractory chronic pain syndromes. The following sequential, prospective, observational case series presents treatment outcome data on a 4-week multidisciplinary chronic pain program for adult patients with complex chronic pain syndromes that were refractory to standard pain management. Prior to enrollment in the program, patients had been treated with pain medications, physical therapy, and interventional procedures. Data were collected and analyzed on variables including pain ratings, healthcare utilization, opioid medication use, and perceived physical functioning at program admission and discharge as well as at intervals of 3 months, 6 months and 12 months post-discharge. Analysis of the data reveal statistically significant improvements in the variables of interest across most time parameters. Results demonstrate that participation in a chronic pain program is an effective intervention for selected patients with refractory pain.

Intraparenchymal migration of an intrathecal catheter three years after implantation

Intrathecal drug administration using implanted catheter and pump systems has been used in routine clinical practice for more than 20 years to treat chronic refractory pain or spasticity. Complications associated with the use of these systems include drug related adverse events as well as technical problems, most of which are related either to the catheter or the procedure. Although traumatic neural damage is exceedingly rare it is usually associated with significant neurological impairment. We present a case of asymptomatic intraspinal migration of an intrathecal catheter three years after an uneventful implantation. To the best of our knowledge, this complication has never been reported before.

Anastrazole and oral contraceptives: a novel treatment for endometriosis

To establish the use of aromatase inhibitors as a therapeutic option for endometriosis. Prospective open-label Food and Drug Administration phase 2 trial with Institutional Review Board approval. Outpatient tertiary care centers. Fifteen premenopausal patients with documented refractory endometriosis and chronic pelvic pain. After a 1-month washout of endometriosis hormone therapies, women took 1 mg anastrazole (Arimidex; AstraZeneca, Wilmington, DE) and one tablet of 20 microg ethinyl estradiol/0.1 mg levonorgestrel (Alesse; Wyeth, Madison, NJ) daily for 6 months. An analog pain scale recorded pelvic pain in daily diaries and surveys at baseline and after each treatment month. Side effects, blood counts, liver and renal function tests, cholesterol levels, and bone density were monitored. Fourteen of 15 patients achieved significant pain reduction. Median pain scores decreased 55% after 6 months, while mean pain scores decreased 40%. Pain reduction comparing each treatment month to baseline achieved statistical significance. Average pain scores began dropping after only 1 treatment month and continued decreasing each additional month. No organ system experienced adverse effects. Estradiol levels were suppressed during treatment. Side effects were mild and improved over time. Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects. This treatment for endometriosis is a promising new modality that warrants further investigation.

Volumetric Image Guidance for Motor Cortex Stimulation: Integration of Three-dimensional Cortical Anatomy and Functional Imaging

Epidural electrical stimulation of the motor cortex is a promising treatment option in patients with intractable pain. Varying rates of success in long-term pain relief have been attributed to inaccurate positioning of the electrode array, partly because the sulcal landmarks are not directly visualized. We describe an integrated protocol for precise electrode placement, combining functional image guidance and intraoperative electrical stimulation in the awake patient. Volumetric rendering of a three-dimensional (3-D) magnetic resonance data set was used to visualize the cortical surface and to superimpose functional magnetic resonance imaging data in six patients with refractory chronic pain. The intraoperative positioning of the quadripolar electrode array was monitored by functional 3-D image guidance. Continuous electrophysiological monitoring and clinical assessment of the motor effects complemented the procedure. Volumetrically rendered 3-D images were advantageous for the location of the burr hole over the perirolandic area by revealing individual cortical morphological features (e.g., the hand knob) and function at the same time. The exact position of the electrodes was verified reliably by cortical stimulation. No complications were observed throughout the procedures. The combination of 3-D functional neuronavigation, intraoperative electrical stimulation, and continuous motor output monitoring in awake patients provides optimal information for the identification of the appropriate somatotopic area of motor cortex. This combined imaging and stimulation approach for electrode positioning offers a safe and minimal invasive strategy for the treatment of intractable chronic pain in selected patients.

Diagnostic Utility of Facet (Zygapophysial) Joint Injections in Chronic Spinal Pain: A Systematic Review of Evidence

Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources, overlapping clinical features, and nonspecific radiologic findings. Diagnostic injection techniques are employed to isolate the source(s) of pain. Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply. Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test (i.e., accuracy, safety and reproducibility). Accuracy must be compared with a "gold" or criterion standard that can confirm presence or absence of a disease. There is, however, no available gold standard, such as biopsy, to measure presence or absence of pain. Hence, there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections. To evaluate accuracy, safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin. A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints. Relevant literature on diagnostic facet injections was identified through database searches. Excluded were abstracts, reviews, book chapters, case reports and studies based on single blocks or blocks without radiologic control. Prospective studies with placebo control, or controlled comparative local anesthetic blocks, were given priority over retrospective studies. Each study was graded using AHRQ and QUADAS criteria. The level of evidence was classified as conclusive, strong, moderate, limited, or inconclusive. Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain. There was moderate evidence in the diagnosis of pain arising from thoracic facet joints. The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. The sensitivity, specificity, false-positive rates, and predictive values of these diagnostic tests for neck and low back pain have been validated and reproduced in multiple studies.

エピドラスコピーに用いる機器(&lt;特集&gt;慢性疼痛治療における医療機器の現状と展望)

わが国では慢性疼痛を有する患者の半数以上が腰痛に罹患し, 高齢化社会の到来と相まって腰痛や坐骨神経痛を診療する機会が非常に多くなってきた. 腰下肢痛を有する大部分の患者では, 個々の病態に対応した保存的治療が第一選択とされ, 保存的治療に抵抗する患者では手術療法などの観血的治療も考慮される. しかし, 保存的治療が奏功しない患者の中には, その全身状態が必ずしも手術療法に耐えうるとは限らない. 近年では, 保存的治療と観血的治療の中間的位置を占めるような, 低侵襲治療法も効果をあげている. 本稿では, 難治性腰下肢痛に対する最新の診断治療法, エピドラスコピー(硬膜外腔内視鏡)について述べる. 歴史 生体の体腔内を観察する機器の歴史は非常に古い. ギリシャ、ローマ時代の遺跡からは今日の直達鏡の原型が出土され, 19世紀にはBozziniによって内視鏡検査に関する最初の記載がなされている. 内視鏡による脊柱管の観察は, 1930年代にはじあて行われた. 当時使用された内視鏡は外径の大きい硬性鏡であったが, 医用画像技術の進歩により直径1mm以下の軟性鏡が開発され, 最近では馬尾の血流や硬膜外腔の構築などについても報告されている.

Use of an implantable drug delivery system for refractory chronic sickle cell pain

An increasing number of chronic sickle cell patients are being treated with sustained-release opioids in the same manner as cancer patients. In a randomized clinical trial of patients with refractory cancer pain, implantable intrathecal drug delivery systems (IDDS) improved clinical success compared to comprehensive medical management alone. We implanted IDDS pumps in two sickle cell patients with refractory bone pain. Both patients achieved rapid and sustained relief of pain, with dramatic reduction in the use of as-needed opioids, crises, and admissions. IDDS may offer relief for sickle cell patients with refractory pain. A prospective trial with more participants is planned.

Poster 6 treatment of chronic refractory knee joint pain with botulinum toxin type A: A report of 2 cases. John Mikuzis, DO (Action Physical Medicine and Rehabilitation, Shorewood, IL), e-mail: jdmikuzis@pol.net

Poster 6 treatment of chronic refractory knee joint pain with botulinum toxin type A: A report of 2 cases. John Mikuzis, DO (Action Physical Medicine and Rehabilitation, Shorewood, IL), e-mail: jdmikuzis@pol.net

Analgesic pharmacology: II. Specific analgesics.

Methods of treatment are different for acute and chronic pain. For acute pain, analgesics such as nonsteroidal anti-inflammatory drugs and opiates are commonly used, sometimes combined with regional anesthesia, such as peripheral nerve block or peridural local anesthesia. The mechanism of transition from an acute to a chronic pain state is poorly understood. Only NMDA receptor antagonists and epidural morphine have shown relatively consistent results as preemptive analgesics. Agents more successfully used to manage chronic pain include those that modify the neurochemistry of the spinal cord dorsal horn, such as tricyclic antidepressants, anticonvulsants, gamma-amino butyric acid agonists, local anesthetic analogs, and NMDA antagonists. Opiates may be used chronically, but tolerance and lack of efficacy may then develop. In selected patients with refractory chronic pain, centrally administered analgesics may be considered, including opiates, dilute local anesthetic, NMDA receptor antagonists, clonidine, midazolam, baclofen, or calcium channel blockers. For both acute and chronic pain, a single agent may be less effective than combinations of analgesics with different mechanisms of action.

One Day Lumbar Epidural Adhesiolysis and Hypertonic Saline Neurolysis in Treatment of Chronic Low Back Pain: A Randomized, Double-Blind Trial

Chronic, refractory low back pain is a common problem. Percutaneous adhesiolysis with hypertonic saline neurolysis was described in the management of chronic refractory low back pain, non-responsive to conservative modalities of management. To determine the ability of percutaneous adhesiolysis and hypertonic saline administration to reduce pain and improve functional and psychological status in patients with chronic low back pain. Randomized, double-blind, controlled trial. A total of 75 patients were studied, with 25 patients in each group. Three types of interventions were included, with Group I serving as control with catheterization without adhesiolysis, followed by injection of local anesthetic, normal saline, and steroid. Group II consisted of catheterization and adhesiolysis, followed by injection of local anesthetic, normal saline, and steroid. Group III consisted of adhesiolysis followed by injection of local anesthetic, hypertonic saline, and steroid. Statistical analysis incorporated intent-to-treat analysis. Visual Analogue Scale pain scores, Oswestry Disability Index, work status, opioid intake, range of motion measurement, and P-3 (R). Significant pain relief was defined as average relief of 50% or greater. Significant improvement was seen in patients in Group II and III, at 3 months, 6 months, and 12 months, compared to baseline measurements, as well as compared to Group I without adhesiolysis. Seventy-two percent of patients in Group III (adhesiolysis and hypertonic neurolysis), 60% of patients in Group II (adhesiolysis only), compared to 0% in Group I (control) showed significant improvement at 12-month follow up. The average number of treatments for one year were 2.76 in Group II and 2.16 in Group III. Duration of significant relief with the first procedure was 2.8 +/- 1.49 months in Group II and 3.8 +/- 3.37 months in Group III. Percutaneous adhesiolysis, with or without hypertonic saline neurolysis, is an effective treatment for chronic low back pain.

Non-opioid analgesics: other: Safety assessment of intrathecal ziconotide treatment for chronic malignant and nonmalignant pain

The objective of this work was to investigate the safety of intrathecal (IT) ziconotide (PRIALTTM) in patients with refractory malignant or chronic nonmalignant pain across multiple studies. This analysis includes safety data from 10 different multicenter studies. Ziconotide titration regimens varied, including forced titration regimens as well as conservative titration to effectiveness. The overall safety of IT ziconotide was examined by monitoring adverse events (AEs) and serious adverse events (SAEs, defined according to FDA criteria). In the 10 studies, 1048 patients were treated with ziconotide. Overall, 88.8% of patients reported at least 1 AE considered by the investigator to be related to ziconotide. The most frequently reported ziconotide-related AEs include abnormal gait (19.2%), memory impairment (19.6%), confusion (28.5%), nystagmus (29.3%), and dizziness (47.5%). SAEs related to ziconotide were reported in 147 patients; meningitis (0.9%), stupor (1.0%), urinary retention (1.0%), dizziness (1.1%), and confusion (3.5%) were the most frequently reported. Four hundred fifty-nine patients discontinued treatment early due to intolerable AEs. Nausea (5.3%), dizziness (6.7%), and confusion (11.7%) most commonly led to discontinuation. Overall, the most common ziconotide-related AEs are nervous system related, as might be expected based on the pharmacology of the drug at higher centers in the central nervous system. Across all studies, most patients in these very refractory populations experienced AEs. There were many early discontinuations, although for a substantial number of patients the risk of AEs was tolerable based on the analgesic benefit of the drug.

Spinal cord lesion after long-term intrathecal clonidine and bupivacaine treatment for the management of intractable pain

Long-term intrathecal drug administration using implanted pumps is increasingly used in the treatment of chronic refractory pain [ Anderson and Burchiel 1999, Neurosurgery 44 (1999) 289; Krames 2002, Best Pract Res Clin Anaesthesiol 16 (2002) 619; Wallace 2002, Neurology 59 (2002) S18]. Extensive clinical experience over the last 15 years suggests that in selected cases the technique is safe, although infections, system malfunction and drug-related complications have been reported. In most cases, drug-related spinal cord injuries have resulted from the compression of a spinal inflammatory mass or abcess rather than from a direct neurotoxic effect. We report on a case of toxic spinal cord lesion occurring after more than 3 years of uneventful continuous infusion of a mixture of bupivacaine and clonidine.

Radiotherapy in painful heel spurs (plantar fasciitis)—results of a national patterns of care study

PurposeAfter a general patterns of care study, the German Cooperative Group on Radiotherapy for Benign Diseases conducted a multicenter cohort study to analyze radiotherapy (RT) in painful heel spur syndrome (HSS). Methods and materialsIn 2001, a patterns of care study was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful HSS were assessed. In addition, the functional and subjective outcomes were evaluated. ResultsOf the institutions, 146 (79.3%) returned the questionnaire: 10 (6.8%) reported no clinical experience with RT for HSS, and 136 (93.2%) treated 3621 patients annually, a median of 23 cases/institution. The indications for treatment were chronic or therapy refractory pain. The total dose ranged between 2.5 and 18.75 Gy (median 6), and single fractions ranged between 0.3 and 1. 5 Gy (median 1). Of the responding institutions, 44.9% applied two fractions and 37.5% three fractions weekly. RT was delivered with orthovoltage units (38.2%), linear accelerators (53.7%), 60Co units (5.1%), or other treatment units (3%). Seventy-six institutions presented their retrospective clinical evaluation in a total of 7947 patients. Pain reduction for at least 3 months was reported in 70%, and persistent pain reduction was reported in 65% of the treated patients. In 19 institutions, a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed. ConclusionThe study comprised the largest number of cases reported of RT for painful HSS. Despite variations in the daily RT practice, this national patterns of care study represents a very large number of painful and refractory HSS cases that were treated effectively with RT.

Clinical Remission of Chronic Refractory Pelvic Symptoms in Three Men.

We report on three American men with chronic refractory pelvic pain, urinary symptoms, and sexual dysfunction who traveled to the Philippines for treatment. In the Manila Genitourinary Clinic, the patients were treated with microbial diagnosis, antimicrobial therapy, and 19, 27, and 21 prostatic massages respectively. All three patients underwent resolution of symptoms.

Are oral cannabinoids safe and effective in refractory neuropathic pain?

Although cannabinoids have anti-hyperalgesic effects in animal models of nerve injury, there are currently very few prospective trials of the efficacy of cannabinoids in neuropathic pain in humans. This open label prospective study investigated the safety, tolerability and analgesic benefit of oral Δ-9-tetrahydrocannabinol (THC) titrated to a maximal dosage of 25 mg/day in 8 consecutive patients with chronic refractory neuropathic pain. Spontaneous ongoing and paroxysmal pain, allodynia and paresthesias were assessed. The sensory and affective components of pain using the McGill pain questionnaire, quality of life, mood, anxiety and functionality were also evaluated. Seven patients suffered from side effects necessitating premature arrest of the drug in 5 of them. THC (mean dosage: 16.6 ± 6.5 mg/day) did not induce any significant effects on ongoing and paroxysmal pain, allodynia, quality of life, anxiety/depression scores and functional impact of pain. These results do not support an overall benefit of THC in pain and quality of life in patients with refractory neuropathic pain.

Targeted etanercept for treatment-refractory pain due to bone metastasis: Two case reports

Background: Parallel bodies of research suggest both a central role for osteoclasts in tumor-induced destruction of bone and the ability of biologic tumor necrosis factor-alpha (TNF-alpha) antagonists to attenuate the osteoclast-mediated bone destruction that accompanies a variety of nonmalignant disorders. Additional studies have implicated TNF-alpha in the promotion of osteoclast-mediated malignant osteolysis and the pathogenesis of neuropathic pain. TNF-alpha antagonists have the potential to interfere in both processes. Objective: This article reviews the cases of 2 patients with treatment-refractory pain due to cancer metastases to bone who were given targeted injections of the biologic anti-TNF agent etanercept based on its potential to interfere directly with both malignant activation of osteoclasts and neuropathic pain. Methods: One patient had a diagnosis of non-small cell lung cancer and the other had a diagnosis of breast cancer. Both presented with treatment-refractory pain due to bone metastases. The 2 patients received etanercept 25 mg by targeted SC injection in anatomic proximity to the site of spinal metastasis for relief of their treatment-refractory pain. Results: Both patients experienced rapid, substantial, and sustained relief of chronic refractory pain at the treatment site after targeted administration of etanercept. Symptomatic improvement was correlated with objective measures of improvement, including weight gain in 1 patient and decreased uptake of radioactive tracer at the targeted site on positron emission tomography in the other. Conclusions: Etanercept delivered by targeted SC injection may be of clinical benefit in selected patients with treatment-refractory pain caused by bone metastases. Clinical trials are needed to define the potential benefit of biologic TNF-alpha antagonists in the treatment and prevention of malignant osteolysis.

Arthroscopic management of painful and stiff scapulothoracic articulation

We present the case of a patient who had chronic refractory scapulothoracic pain accompanied by the loss of scapulothoracic motion. Despite intensive physical therapy, the insidious onset of scapulothoracic pain and stiffness progressed. A wide range of diagnostic tests did not show a systemic, anatomic, or neurologic cause for the disorder. Finally, the patient elected to undergo an arthroscopic release and decompression of the scapulothoracic articulation. The patient had a dramatic response to surgery; the pain was gone immediately, and by 4 months after surgery, her scapulothoracic motion was evaluated as symmetric. One year after the surgery, she maintained an active lifestyle and was extremely satisfied with the result. Progressive and painful loss of shoulder motion in the case reported was due to a rare adhesive inflammation of the scapulothoracic bursa, which was successfully treated using arthroscopic resection. Arthroscopy of the scapulothoracic articulation is an option to treat scapulothoracic abnormalities, especially bursitis, but long-term clinical studies are needed to strongly recommend this emerging treatment option.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: pp E28