Changes In Visual Analog Scale Scores Research Articles

Retrospective Evaluation of the Effectiveness of Superior Hypogastric Plexus Block in Chronic Pelvic Pain

Objective: Chronic pain is a cause that negatively affects the quality of life and functional capacity. As with most chronic pain syndromes, chronic pelvic pain requires a multimodal approach. Hypogastric plexus blockade and neurolysis may be effective in cases that do not respond to conservative treatments. In this study, we retrospectively evaluated the effect of hypogastric plexus blockade in patients with chronic pelvic pain. Methods: Forty patients with chronic pelvic pain (duration of pain> 6 months) who underwent hypogastric plexus block under fluoroscopy were evaluated retrospectively. Neurolysis was performed after diagnostic block in 19 patients with chronic pelvic pain associated with pelvic cancer. Results: While the visual analogue scale (VAS) of the patients who underwent superior hypogastric block was 8.8 before the procedure, the VAS scores at 1 month, 3 months and 6 months after the procedure were recorded as 3.7, 2.2, and 1.1, respectively (p<0.05). While the mean Oswestry Disabilty Index (ODI) score of the patients before the procedure was 46.0% (severe disability), it was recorded as 3% at the 6th month. The changes in VAS and ODI scores were statistically significant (p<0.05). Conclusion: Hypogastric plexus blockade should be considered as an effective treatment option in the treatment of chronic pelvic pain. Keywords: Pelvic pain, nerve block, pain management, chemical neurolysis, fluoroscopy

Feasibility of a school-based mental health program implementation to improve the status of depression and quality of life of mothers of children with autism spectrum disorders in urban Bangladesh: MENTHOL study.

We assessed the feasibility of implementing psychological counseling services (PCS) for mothers of children with autism spectrum disorders (ASD) integrated within special education settings in urban Bangladesh. In two special education schools for ASD in Dhaka City, trained female psychologists screened mothers using the Patient Health Questionnaire (PHQ-9). PCS was administered to all the mothers irrespective of a diagnosis of depression. Mothers with a PHQ-9 score >4 who met criteria for a major depressive episode (MDE) based on the DSM-IV Structured Interview Axis I Disorders (SCID-I) were also administered skill-building training through monthly home visits to support ASD care. The level of depression was assessed by the Depression Measurement Scale (DMS), and quality of life (QoL) was measured by Visual Analogue Scale (VAS) of EQ5D5L scale before and after PCS. Among 188 mothers enrolled in the study, 81 (43%) received PCS, and 27.1% (22) had MDE. In the first month, 73 sessions were scheduled and 60 completed (85%). In the last month, 53 sessions were scheduled and 52 completed (98%). The mean DMS score decreased from 79.5 ± 23 to 60 ± 20 (p = 0.004), and DMS scores were significantly higher among mothers with MDE (97.8 ± 12.1 v. 69.9 ± 22.1; p < 0.001) compared to those without MDE (72.7 ± 22.6 v. 56.1 ± 18.1; p = 0.003). The mean VAS score improved from 70.3 ± 14.1 to 80.2 ± 13.3 (p = 0.001) between the first and the last session. Changes in DMS were negatively correlated with changes in VAS scores (β: -0.213, 95% CI 0.370 to -0.056). Within special education schools for ASD in urban Bangladesh, it was feasible to administer an integrated program of PCS for mothers of children with ASD by trained psychologists who were able to screen and intervene to reduce their level of depression and improve their quality of life.

Effectiveness and Safety of Codeine and Levodropropizine in Patients With Chronic Cough.

BackgroundRecent progress in chronic cough management includes controlling cough triggers and hypersensitivity using antitussives. Therefore, we investigated the effects and safety outcomes of antitussives, codeine and levodropropizine, in patients with chronic cough.MethodsWe conducted an open-label, randomized comparative trial with newly referred patients with chronic cough. Patients were orally administered codeine (60 mg/day) and levodropropizine (180 mg/day) for 2 weeks. Cough severity, including the visual analog scale (VAS), Cough Symptom Score (CSS), Leicester Cough Questionnaire (LCQ), and safety for each treatment were assessed. The primary outcome was VAS score changes before and after 2 weeks of treatment.ResultsAmong the 88 participants, 45 and 43 in the codeine and levodropropizine groups, respectively, were included in the analysis. Changes in the VAS score were higher in the codeine group than in the levodropropizine group (35.11 ± 20.74 vs. 19.77 ± 24.83, P = 0.002). Patients administered codeine also had improved CSS (2.96 ± 2.35 vs. 1.26 ± 1.89, P < 0.001) and LCQ (3.28 ± 3.36 vs. 1.61 ± 3.53, P = 0.025) than those administered levodropropizine. Treatment-related adverse events, including drowsiness, constipation, and headaches, were more frequent in the codeine group than in the levodropropizine group. However, no significant differences existed in the adverse events leading to discontinuation.ConclusionCodeine is an effective and generally well-tolerated antitussive for chronic cough. However, it may induce side effects in some patients. Individual responses and adverse events should be carefully monitored when codeine is used to treat chronic cough.

Results of an Interim Analysis of a Prospective Multicenter Study Assessing Radiographic and Patient Outcomes Following Triplanar Tarsometatarsal Arthrodesis with Early Weightbearing

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing.Methods:This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot are eligible for this study. Patients are treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, range of motion (ROM), return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) are evaluated post- operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up.Results:At time of analysis, 121 patients had undergone TMTA with at least 6 months of follow-up. Mean age was 40.6 (range:15- 58) years, and 91% of patients were female. Mean (SD) days to protected weightbearing in CAM boot, return to work, and return to full work were 8.2 (6.8), 24.0 (29.5), and 51.2 (44.0), respectively. Significant improvements (p<0.05) from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS score was -4.0 (-4.5, -3.6); Walking/Standing, Pain, and Social Interaction (MOxFQ domains) change was -38.6 (-43.6, -33.5), -41.0 (-45.8, -36.2), and -40.5 (-45.3, -35.7), respectively; and physical function (PROMIS) change was 8.7 (6.6, 10.8).Conclusion:These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.

Comparison of the Effects of Neurocognitive Therapeutic Exercise(CTE) and Conventional Therapy on the Reduction of Shoulder Pain in Farm Worker

Comparison of the effects of neurocognitive therapeutic exercise(CTE) and conventional therapy on the reduction of shoulder pain in farm workers. The aim of this randomized controlled pilot study was to evaluate the effectiveness of neurocognitive therapeutic exercise(CTE) and conventional exercise therapy in reducing work-related shoulder pain. Twenty elderly patients with work-related shoulder pain were randomly assigned to one group: neurocognitive group or conventional group. Both sessions lasted 30 min, three times a week for 8 weeks, and the assessments were blinded. Outcome measures included the visual analog scale (VAS) score, structured questionnaire, and rapid entire body assessment (REBA). Active range of motion (AROM) of shoulder abduction and parametric statistical tests were performed using paired and independent t-tests. Both groups experienced improvements in all outcomes measures relative to the baseline values. Changes in VAS score (p=.151) showed no significant differences between the two groups. The neurocognitive therapeutic exercise could be a safe and more useful strategy for improving REBA (p=.001) and AROM (p=.001). Neurocognitive rehabilitation is effective in reducing and improving function in farm workers with shoulder pain.

Trial of Nemolizumab and Topical Agents for Atopic Dermatitis With Pruritus

To evaluate the effect of nemolizumab, a subcutaneously administered humanized monoclonal antibody against interleukin 31 receptor A and concomitant topical medications and oral antihistamines versus placebo on atopic dermatitis (AD)-induced pruritus.A double-blind, placebo-controlled, parallel group, multicenter phase 3 study population of Japanese adolescents and adults aged ≥13 years (n = 215; median ages: 39 years [nemolizumab] and 40.5 years [placebo]) with a confirmed diagnosis of AD, weight of 30 to 120 kg, inadequate response to medium-potency topical corticosteroids or topical calcineurin inhibitors and oral antihistamines, and elevated visual analog scale (VAS) for pruritus and Eczema Area and Severity Index (EASI) scores.Patients were randomly assigned in a 2:1 ratio to receive nemolizumab 60 mg subcutaneously (n = 143) versus placebo (n = 72) every 4 weeks, for 16 weeks total. Patients in both groups were allowed to continue the use of topical corticosteroids, calcineurin inhibitors, oral antihistamines, and topical moisturizers. Patients were excluded if they were on other biological therapy, phototherapy, hyposensitization therapies, or other systemic treatments. The primary end point was the percentage change in weekly mean VAS score for pruritus from the baseline, whereas secondary end points included the change in VAS score to week 4 and changes in EASI score, Dermatology Life Quality Index score and Insomnia Severity Index. Intention-to-treat models were used for analysis of all end points with patients who received at least 1 dose of nemolizumab or placebo. A mixed-effects model for repeated measures was used to analyze weekly scores. The mixed-effects model for repeated measures, analysis of covariance, and intention-to treat analysis were applied to other end points.After 16 weeks of therapy, the mean change in VAS score from the baseline to week 16 was −42.8% ± 2.6 in the nemolizumab group versus −21.4% ± 3.6 in the placebo group, resulting in a −21.5% difference in the 2 groups (P < .001). The initial 4 week change in VAS score was −34.4% in the nemolizumab group versus −15.3% in the placebo group, resulting in a −19.3% difference between the groups. The change in EASI score >16 weeks was −45.9% (nemolizumab) versus −33.2% (placebo). In the nemolizumab group, 67% of patients had a change in Dermatology Life Quality Index score of ≥4 points, and 55% of patients had a change in an ISI score of ≤7 at week 16 versus 50% and 21%, respectively, in the placebo group. The most commonly reported adverse event was worsening AD in 24% of patients in the nemolizumab group and 21% of patients in the placebo group.Patients with moderate to severe pruritus associated with AD, uncontrolled by topical agents and oral antihistamines, who received nemolizumab saw a reduction in pruritus based on several scoring systems, compared with those who received the placebo >16 weeks.Currently, the only Food and Drug Administration–approved biological therapy available for moderate to severe AD is dupilumab, approved for those aged ≥6 years. Although this study included mostly adults, adolescents were included and did show some efficacy for reducing pruritus in AD. However, it is concerning that >20% of patients in the intervention group had worsening AD symptoms. Thus, further controlled trials, including the pediatric population, are needed to be able to assess overall effect on AD control.

Trigger Point Injections Followed by Immediate Myofascial Release in the Treatment of Pelvic Floor Tension Myalgia

<h3>Study Objective</h3> To determine whether adding pelvic floor physical therapy (PFPT) with myofascial release immediately following pelvic floor trigger point injection (PFTPI) provides better pain relief than pelvic floor trigger point injection alone. <h3>Design</h3> A retrospective chart review of patients with pelvic floor tension myalgia refractive to conservative treatment (physical therapy and muscle relaxants) who underwent PFTPI alone or PFTPI immediately followed by PFPT. Visual analogue scale (VAS) pain scores were recorded pre-treatment and 2 weeks post treatment. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> Female patients being treated for pelvic floor tension myalgia. <h3>Interventions</h3> Trigger point injections using 20 mL Ropivacaine 5 mg/mL (0.5 %) with or without addition of pelvic floor physical therapy with myofascial release for myofascial pelvic pain within 1-2 hours after injection. <h3>Measurements and Main Results</h3> Sixty-five patients with pelvic floor tension myalgia refractive to primary therapy and proceeding to PFTPI were included in the final study analysis. Twenty-two patients underwent trigger point injections alone and Forty-three patients underwent PFTPI immediately followed by PFPT. Demographic and clinical characteristics were comparable between groups. PFTPI improved VAS pain scores for both groups of patients. The median pre-treatment score was 8 for both groups of patients. The median post-treatment score was 6 for the PFTPI only group and 4 for the PFTPI followed by PFPT group, giving a median change in VAS score of 2 and 4 respectively (p=0.057). 74.5% of patients in the PFTPI followed by PFPT group had a change in VAS score greater than 2; whilst 45.4% of patients in the PFTPI only group had a change in VAS score greater than 2 (p=0.029). <h3>Conclusion</h3> Pelvic floor trigger point injection immediately followed by pelvic floor physical therapy with myofascial release seems to offer more improvement in pain for patients with pelvic floor tension myalgia. This may be due to tolerance of deeper physical therapy immediately following injections.

Effects of Transcutaneous Spinal Direct Current Stimulation (tsDCS) in Patients With Chronic Pain: A Clinical and Neurophysiological Study.

Background and Aims: Chronic pain is a complex clinical condition, often devastating for patients and unmanageable with pharmacological treatments. Converging evidence suggests that transcutaneous spinal Direct Current Stimulation (tsDCS) might represent a complementary therapy in managing chronic pain. In this randomized, double-blind and sham-controlled crossover study, we assessed tsDCS effects in chronic pain patients.Methods: Sixteen patients (aged 65.06 ± 16.16 years, eight women) with chronic pain of different etiology underwent sham and anodal tsDCS (anode over the tenth thoracic vertebra, cathode over the somatosensory cortical area: 2.5 mA, 20 min, 5 days for 1 week). As outcomes, we considered the Visual Analog Scale (VAS), the Neuropathic Pain Symptom Inventory (NPSI), and the components of the lower limb flexion reflex (LLFR), i.e., RIII threshold, RII latency and area, RIII latency and area, and flexion reflex (FR) total area. Assessments were conducted before (T0), immediately at the end of the treatment (T1), after 1 week (T2) and 1 month (T3).Results: Compared to sham, anodal tsDCS reduced RIII area at T2 (p = 0.0043) and T3 (p = 0.0012); similarly, FR total area was reduced at T3 (p = 0.03). Clinically, anodal tsDCS dampened VAS at T3 (p = 0.015), and NPSI scores at T1 (p = 0.0012), and T3 (p = 0.0015), whereas sham condition left them unchanged. Changes in VAS and NPSI scores linearly correlated with the reduction in LLFR areas (p = 0.0004).Conclusions: Our findings suggest that tsDCS could modulate nociceptive processing and pain perception in chronic pain syndromes.

Meeting Patient Expectations or Achieving a Minimum Clinically Important Difference: Predictors of Satisfaction among Lumbar Fusion Patients.

Study DesignRetrospective cohort.PurposeTo investigate the impact of meeting a patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.Overview of LiteratureFew studies have compared if MCID achievement or meeting preoperative expectations for pain reduction affects patient satisfaction.MethodsA surgical database was reviewed for eligible patients who underwent lumbar fusion. Patient satisfaction and Visual Analog Scale (VAS) for back and leg pain were the outcomes of interest. Meeting expectations was calculated as a difference of ≤0 between preoperative expectations and postoperative VAS scores. MCID achievement was calculated by comparing changes in VAS scores with established values. Meeting preoperative expectations or MCID achievement as predictors of patient satisfaction was evaluated using regression analysis.ResultsA total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back and VAS leg (p<0.001). At 1 year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg. Similarly, at 1 year, 77.3% and 71.3% of patients achieved MCID for VAS back and leg, respectively. Meeting expectations for VAS back was significantly associated with patient satisfaction at all postoperative timepoints; however, MCID achievement only demonstrated a significant association with patient satisfaction at 6 and 12 weeks (all, p≤0.024). Meeting VAS leg expectations and MCID achievement both demonstrated a significant association with patient satisfaction at all postoperative timepoints (all, p≤0.02). No differences between MCID achievement and meeting expectations as predictors of satisfaction were noted.ConclusionsThe majority of patients achieved MCID and had their back and leg pain expectations met by 1 year. Both measures were significant predictors of patient satisfaction and suggest that MCID achievement may act as a suitable substitute for patient satisfaction.

The most effective local infiltration analgesic (LIA) in reducing overall opioid use and nausea in the acute postoperative period of shoulder arthroplasty patients; a prospective, double-blind, randomized observational study

IntroductionEffective pain management in the immediate postoperative period is a crucial first step in the treatment of shoulder arthroplasty patients. Previous studies suggested that local infiltrative analgesia (LIA), specifically with Liposomal Bupivacaine (LB), is equivalent to interscalene nerve block (ISNB) for postoperative pain management. This prospective, randomized, double-blinded study seeks to measure the difference in efficacy between the 3 widely-used LIA cocktail formulations: Bupivacaine, LB, and Ropivacaine. MethodsBetween 2018 and 2019, 179 consecutive patients underwent reverse total shoulder arthroplasty for end-stage shoulder arthropathy. Patients were enrolled and randomized in a prospective, double-blind clinical trial to receive one of 3 LIA injections before skin incision and after skin closure: 0.25% Bupivacaine ±Epinephrine, 1.3% LB, or 0.5% Ropivacaine cocktail with Ketorolac. There were 67 patients excluded due to preoperative comorbidities or consent refusal. The eligible 112 patients were monitored for 24 hours after surgery. Mean age was 67.9 years (range: 40-90 years). The primary outcome measure was the mean preoperative Visual Analog Scale (VAS) pain score, mean postoperative VAS score during the 24-hour postoperative period, and change in mean VAS score. The secondary outcome measure was total Morphine Milligram Equivalents (MMEs) used, antiemetic use, and laxative use during the same period. Pre-hoc power analysis found a total sample size of 219 (73 per group) was estimated to detect a significant difference at 80% power and 0.05 Type I error rate. ResultsUse of Bupivacaine, LB, and Ropivacaine resulted in 1.2±2.9, 0.6±3.2, and 0.1±2.8 change in VAS scores, respectively (P=.32). Total postoperative MMEs used were 124.1±115.1, 116±84.5, and 105±96.7 milligrams, respectively (P=.71). There were no statistically significant differences amongst the 3 cocktails for postoperative pain relief or rate of antiemetic/laxatives used.There was a nonsignificant trend toward superior analgesic effect of Ropivacaine compared to Bupivacaine. Ad-hoc power analysis found that the estimated sample sizes required to detect a difference between the Ropivacaine and Bupivacaine treatment for change in VAS score and total MMEs use, were 321 and 1593 patients, respectively. Because of the non-clinically significant differences, continued patient enrollment was terminated. The cost of Bupivacaine was comparable to Ropivacaine ($13.43 and $21.95, respectively), whereas LB cost ($434.96) was 20-30 times higher. ConclusionThere were no differences in clinical efficacy amongst Bupivacaine, LB, and Ropivacaine cocktails for perioperative pain management in shoulder arthroplasty. LB was not clinically advantageous compared to the other two medications and did not justify the increase in cost. Level of EvidenceLevel I; Randomized, Controlled Trial

Use of a combination of N-acetylcysteine and clonazepam to treat burning mouth syndrome

This study was intended to evaluate the clinical efficacy of a combination of N-acetylcysteine (NAC) and clonazepam for treatment of burning mouth syndrome (BMS). A total of 160 patients with BMS were divided into 3 groups: group 1 received NAC (400 mg/d), group 2 received clonazepam (0.5 mg/d), and group 3 received both NAC and clonazepam. We evaluated symptom relief after 8 weeks of treatment using a visual analog scale (VAS). To assess oral health-related quality of life, we used the validated Korean version of an oral health impact profile (OHIP-14K). The overall response rates of the 3 groups were 60.3%, 51.3%, and 80.0%, respectively. The mean VAS and OHIP-14K scores significantly decreased in all groups after the 8-week treatments. The VAS score changes were -12.2 ± 19.5, -10.0 ± 14.1, and -21.0 ± 24.6, respectively (P = .001), in the 3 groups and the OHIP-14K changes were -2.3 ± 9.2, -4.4 ± 6.9, and -8.7 ± 10.3, respectively (P = .020). Group 3 showed significantly larger differences in VAS and OHIP-14K scores than group 2, before and after treatment. In the treatment of BMS, the NAC/clonazepam combination therapy was more effective than either monotherapy.

The effect of gender differences on the use of valproic acid for migraine prophylaxis

Aim: The efficacy of the drugs used for migraine prophylaxis remains unclear. At our headache polyclinic, when we observed the difference in prophylactic response especially in valproic acid (VA) treatment between genders, the response of male was found to be better than that of females so we wanted to document this difference by collecting data retrospectively&#x0D; Material and Method: 46 chronic migraine without aura patients with VA who were enrolled in our headache outpatient clinic between 2015 - 2018 were included in the study (29 male, 17 female). In these patients, after VA the frequency of montly attacks between sexes, changes in VAS (Visual analogue scale) scores, single VA prophylaxis and the addition of a second prophylaxis drug were evaluated. &#x0D; Results: None of the men needed an additional second drug while 11 of 17 women needed the addition of a second drug. There was no gender difference in monthly attack frequency before treatment, whereas monthly attack frequency after treatment with VA was found to be significantly lower in men ( before treatment; female 20,9±11,3 male 17,7±11,5, p&gt;0.05) (after treatment; male 1,2±5,5 female 12,0±12,2, p0.05)(after treatment; female 4,4±2,8 male 2,3±2,8, p

Selective extraforaminal nerve root block for management of lumbar radiculopathy

Lower back pain with radiculopathy is one of the common complaints that patient presents to an orthopaedician. Study was done to assess effect of extraforaminal Selective Nerve Root Block (SNRB) in management of lumbar radiculopathy in 50 patients between December 2019 and June 2020 at Bapuji Medical College and Chigateri General Hospital, Davanagere, Karnataka, India. Extraforaminal SNRB was performed and Visual Analogue Scale (VAS) scores recorded pre procedure, immediate post procedure, one month and 6 months post procedure. Significant decrease (p&lt;0.001) in VAS scores immediate post procedure by 5 or more points in 25%; by 3-4 points in 44% and 1-2 points in 6% of the patients obtained. One month post procedure showed statistically significant results (p&lt;0.005) owing to change in VAS score by 1-2 points in 84% (42) patients and no change or increase in the VAS scores only in 10%(5) patients. VAS scores at 6th month showed statistically significant results (p&lt;0.005) with reduction of VAS scores in 46.34% (19), retention of VAS score 0 in 31.70% (13) and no change or increase in VAS scores in only 21.95% (9) patients. Our study concludes that extraforaminal SNRB acts as excellent diagnostic tool and therapeutic modality for immediate and long term pain management in lumbar radiculopathy. Increase in the pain scores at 6th month (p=0.2) shows that recurrence of symptoms is a possibility. Further randomized control studies with larger study population, association of patient factors affecting extraforaminal SNRB would give better insight and knowledge of the factual data.

Immediate Pain Relief at Time of Corticosteroid Injection for Idiopathic Adhesive Capsulitis as a Predictor of Eventual Outcomes.

Background:Corticosteroid injection and physical therapy remain the mainstay of treatment for idiopathic adhesive capsulitis of the shoulder; however, a certain percentage of patients will not improve using these interventions and will require manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA).Purpose:To evaluate whether the immediate pain reduction after fluoroscopic-guided, mixed anesthetic-corticosteroid injection for idiopathic adhesive capsulitis is related to the eventual need for LOA/MUA or a repeat glenohumeral steroid injection.Study Design:Case-control study; Level of evidence, 3.Methods:This single-institution study involved patients undergoing fluoroscopic glenohumeral corticosteroid injection for a diagnosis of idiopathic adhesive capsulitis between 2010 and 2017. Included were patients with a minimum of 1-year postinjection follow-up and visual analog scale (VAS) pain scores from immediately before and after the injection. The primary analysis was the relationship between patients with an immediate change in VAS score after injection and those who underwent LOA/MUA. A repeat glenohumeral injection was also evaluated as an outcome. Receiver operator characteristic curves and a multivariate binomial logistic regression analysis were performed.Results:Overall, 739 shoulders in 728 patients (mean age, 52.6 years; 68% women) were included, of which 38 (5.1%) underwent LOA/MUA and 209 (28%) underwent repeat injections. The immediate change in the VAS score was not significantly associated with the eventual need for LOA/MUA. Preinjection VAS and immediate postinjection VAS scores were not significant predictors of eventual LOA/MUA or subsequent injection. For all 3 predictors, the area under the receiver operator characteristic curve classified them as extremely poor discriminators.Conclusion:The immediate pain response to a fluoroscopic-guided glenohumeral injection for idiopathic shoulder adhesive capsulitis was not predictive of the eventual need for LOA/MUA or subsequent injection. Patients can be counseled that even if their initial pain response to an injection is poor, they still have an excellent chance of avoiding surgery, as the overall rate of LOA/MUA was low (5.1%).

Efficacy and safety of low-dose naltrexone in painful diabetic neuropathy: A randomized, double-blind, active-control, crossover clinical trial.

There is a need for newer therapies for chronic painful diabetic neuropathy as the existing drugs have their own limitations. Clinical trials on low-dose naltrexone (1-5 mg/d) showed efficacy and safety in certain chronic painful conditions, but not in painful diabetic neuropathy. Hence the present study was planned. Sixty-seven participants with painful diabetic neuropathy were randomized to receive either 2 mg naltrexone or 10 mg amitriptyline daily following a 2-week run-in period. The participants were followed up every 2 weeks for a total of 6 weeks. Up-titration was done (to 4 mg naltrexone or 25/50 mg amitriptyline) if the pain reduction was less than 20% on the visual analog scale (VAS) during the next follow-up visit. Efficacy was assessed using the change in VAS score at the end of 6 weeks from baseline. Safety was evaluated at each follow-up visit. After 2 weeks of washout period, the participants were crossed over to receive the comparator drug for another 6 weeks with similar evaluations. The difference (confidence interval) in the change in VAS score between groups from baseline was 1.64 (-0.92 to 4.20) in per-protocol analysis and 1.5 (-1.11 to 4.13) in intention-to-treat analysis. Eight and fifty-two adverse events were reported in the naltrexone and amitriptyline groups, respectively (P < .001). The most common adverse events were mild diarrhea with naltrexone and somnolence with amitriptyline. Low-dose naltrexone exhibited similar efficacy and a superior safety profile compared with amitriptyline in painful diabetic neuropathy.

Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BackgroundThis study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA). MethodsPatients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications. ResultsCompared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates. ConclusionAdding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.

The short-term efficacy of electrical pudendal nerve stimulation versus intravesical instillation for the urethral pain syndrome: a randomized clinical trial.

Urethral pain syndrome is a chronic condition characterized by disturbing feeling or server pain sensed at the urethra without specific treatment. This double-center, two-arm controlled trial aimed to explore the efficacy of electrical pudendal nerve stimulation (EPNS) versus intravesical instillation (II) of heparin and alkalinized lidocaine for urethral pain syndrome (UPS). Eighty eligible patients took three sessions of EPNS, or 1 session of II per week, for 6consecutive weeks. The primary end point was the change of pelvic pain and urgency/frequency symptom (PUF) score from baseline to week 6. Secondary outcome measures included changes of visual analogue scale (VAS) score and three sub-score extracted from PUF score. The enrolled participants were all included in the intention-to-treat analyses, and baseline characteristics between the two groups were well balanced. The post-treatment PUF score decreased by 10.0 (7.00, 16.50) in the EPNS group, and by 7.0 (3.00, 10.00) in the II group. At the closure of treatment, the medians of changes in symptom score, bother score, pain-related score and VAS score were 6.50 (4.25, 10.00), 4.00 (2.00, 6.00), 6.00 (5.00, 8.00),4.50 (2.25, 6.00), respectively, in the EPNS group, and 4.00 (2.00, 7.00), 3.00 (1.00, 3.00), 3.00 (2.00, 6.00), 2.00 (1.00, 4.00), respectively, in the II group. All the between-group differences were statistically significant. Compared with the II, the EPNS results in superior pain control and better relief of lower urinary tract symptoms, and deserves further attention. ClinicalTrials.gov (NCT03671993).

Evidence of Cochlear Synaptopathy and the Effect of Systemic Steroid in Acute Idiopathic Tinnitus With Normal Hearing.

To evaluate the electrophysiologic evidence of cochlear synaptopathy and the effects of systemic steroids in acute idiopathic tinnitus with normal hearing. Retrospective review of medical data. Tertiary referral center. Fifty-nine patients who experienced acute-onset idiopathic tinnitus (within 12 weeks) with normal hearing and the same number of age- and pure-tone threshold-matched control groups. Electrophysiologic studies of the auditory pathway, oral steroids, and ginkgo biloba. Pure-tone thresholds, wave I and wave V amplitudes of the auditory brainstem response (ABR), tinnitus handicap inventory (THI), and visual analog scale (VAS). Significantly reduced ABR wave I amplitude and wave I/wave V ratio were found in the tinnitus group compared with the no tinnitus group. Age and pure-tone threshold were significantly correlated with reduced wave I amplitude and small wave I/wave V ratio. The THI and VAS scores were decreased at 3 and 12 weeks after steroid administration; however, overall changes in THI and VAS scores were not significantly different between the steroid and ginkgo biloba groups. Potential cochlear synaptopathy was suspected in the early stage of acute idiopathic tinnitus, even in patients with normal hearing. Age and hearing threshold were potentially associated with the development of cochlear synaptopathy. Low-dose oral steroids and ginkgo biloba induced early subjective relief of tinnitus, which maintained up to 12 weeks, however, those changes did not differ between groups.

Comparison Between Three- and Four-Level Anterior Cervical Discectomy and Fusion: Patient-Reported and Radiographic Outcomes

We compared the long-term clinical and radiographic outcomes after 3- and 4-level anterior cervical discectomy and fusion (ACDF) in a retrospective cohort study. Patients who had undergone primary 3- or 4-level ACDF were retrospectively identified. The demographic data and patient-reported outcome measures (PROMs) were collected through a review of the medical records. PROM surveys were administered preoperatively for baseline measurements and at 1 year postoperatively. The surveys included the Neck Disability Index, 12-item short-form physical component summary, 12-item short-form mental component summary, and visual analog scale (VAS) scores for neck and arm pain. The cervical sagittal alignment parameters included C2-C7 lordosis, segmental lordosis, the sagittal vertical axis (SVA), and the T1 slope. Multivariate regression models were used to compare the changes in the PROMs and radiographic measurements over time between 3- and 4-level ACDF. Correlation coefficients were calculated to compare the delta scores for the PROMs and radiographic measurements. The VAS scores for neck and arm pain had significantly improved from baseline in both cohorts. Only the 3-level group showed significant improvements perioperatively in the Neck Disability Index and 12-item short-form physical component summary. No significant differences were found in the improvement in clinical outcomes between the 2 groups. The pooled results demonstrated a significant negative correlation between the perioperative changes in segmental lordosis and VAS scores for arm pain. A significant negative correlation was also found between the perioperative changes in the SVA and 12-item short-form mental component summary and VAS scores for neck pain. C2-C7 lordosis significantly increased postoperatively only in the 3-level ACDF group. Patients undergoing both 3- and 4-level ACDF experienced significant clinical improvement without significant differences between the 2 groups. The radiographic measures of segmental lordosis and SVA also correlated with the changes in clinical outcomes.

Switching From Pregabalin to Mirogabalin in Patients with Peripheral Neuropathic Pain: A Multi-Center, Prospective, Single-Arm, Open-Label Study (MIROP Study).

IntroductionMirogabalin, which is a selective ligand of the α2δ subunit of voltage-gated Ca2+ channels, was recently approved in Japan for peripheral neuropathic pain. The α2δ ligands, including mirogabalin and pregabalin, are associated with significant risk of adverse events (AEs) such as somnolence or dizziness, leading to poor compliance and subsequent inefficacy. Safety and efficacy data for switching patients from pregabalin to mirogabalin are scarce.MethodsThis prospective, single-arm, open-label study involving ten participating centers in Japan recruited patients aged ≥ 20 years with peripheral neuropathic pain [visual analog scale (VAS) score ≥ 40 mm]. Where necessary, patients underwent a 1-week tapering period to reduce their pregabalin dose, after which pregabalin was stopped and mirogabalin dose was increased using a step-wise dose titration. Patients underwent dose increases after the first and second weeks if there were no tolerability issues, followed by the effective doses until the end of the study (4 weeks). The primary endpoint was the incidence of somnolence, dizziness, and peripheral edema; secondary endpoints included changes in VAS score. AEs were monitored for safety.ResultsOf 157 patients who provided informed consent, 152 patients were enrolled; 136 (89.5%) patients completed the study. The overall incidences of somnolence, dizziness, and peripheral edema were 41.4, 15.8, and 2.6%, respectively. Most patients (> 70%) experienced mild AEs, and one patient experienced a severe AE (dizziness). Most patients (> 70%) were able to achieve dose titration to an effective dose. Overall mean VAS score significantly decreased (Δ15.7 mm, p < 0.0001) by the end of the study.ConclusionsMirogabalin switching from pregabalin is well tolerated and effective in pain management for peripheral neuropathic pain using a step-wise titration.Trial RegistrationJapan Registry of Clinical Trials (jRCTs031190113).Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-021-00255-y.