Misinformation Persists in Complementary Health: Evaluating the Reliability and Quality of YouTube-Based Information on the Use of Acupuncture for Chronic Pain.

Introduction: Acupuncture is commonly used to treat chronic pain. Patients often access public social media platforms for healthcare information when querying acupuncture. Our study aims to appraise the utility, accuracy, and quality of information available on YouTube, a popular social media platform, on acupuncture for chronic pain treatment. Methods: Using search terms such as "acupuncture for chronic pain" and "acupuncture pain relief", the top 54 videos by view count were selected. Included videos were >1 minute duration, contained audio in English, had >7000 views, and was related to acupuncture. One primary outcome of interest was categorizing each video's usefulness as useful, misleading, or neither. Another primary outcome of interest was the quality and reliability of each video using validated instruments, including the modified DISCERN (mDISCERN) tool and the Global Quality Scale (GQS). The means were calculated for the video production characteristics, production sources, and mDISCERN and GQS scores. Continuous and categorical outcomes were compared using Student's t-test and chi-square test, respectively. Results: Of the 54 videos, 57.4% were categorized as useful, 14.8% were misleading, and 27.8% were neither. Useful videos had a mean GQS and mDISCERN score of 3.77±0.67 and 3.48±0.63, respectively, while misleading videos had mean GQS and mDISCERN score of 2.50±0.53 and 2.38±0.52, respectively. 41.8% of the useful videos were produced by a healthcare institution while none of the misleading videos were produced by a healthcare institution. However, 87.5% of the misleading videos were produced by health media compared to only 25.8% of useful videos from health media. Discussion: As patients increasingly depend on platforms like YouTube for trustworthy information on complementary health practices such as acupuncture, our study emphasizes the critical need for more higher-quality videos from unbiased healthcare institutions and physicians to ensure patients are receiving reliable information regarding this topic.

Atypical dermatologic manifestations in complex regional pain syndrome: a case report.

BACKGROUND: Complex regional pain syndrome is a chronic pain condition characterized by autonomic dysfunction, changes in sympathetic and vasomotor activity, and sensory and motor changes. Complex regional pain syndrome is a clinical diagnosis and may occur after trauma or surgery. Complex regional pain syndrome-related pain may occur spontaneously and is out of proportion with the inciting event. We report herein the rare case of a man who developed concomitant painful generalized ulcerations after diagnosis of complex regional pain syndrome. CASE PRESENTATION: A 43-year-old Caucasian male with history of four-extremity complex regional pain syndrome type 2 secondary to right rotator cuff surgery performed at an outside hospital presented to a tertiary care center for treatment of generalized ulcerations on all extremities of unknown etiology. Dermatology performed an extensive work-up including laboratory evaluations and biopsies, which were relatively unremarkable. His ulcers were treated with vinegar-based dressings, hydrotherapy, and irrigation and debridements. He was started on methadone (replacing a home fentanyl patch), ketamine infusion, and amitriptyline in addition to his home adjuncts. He obtained good symptom control, improved sleep, and diminished cognitive slowing, compared with his fentanyl patches. CONCLUSION: This case report emphasizes an atypical case of generalized ulceration formation in the setting of complex regional pain syndrome. This case highlights the challenging nature of treating complex regional pain syndrome and using multimodal analgesia to target various nociceptive receptors to successfully reduce symptoms.

Comparative Effectiveness of Landmark-guided Greater Occipital Nerve (GON) Block at the Superior Nuchal Line Versus Ultrasound-guided GON Block at the Level of C2: A Randomized Clinical Trial (RCT).

OBJECTIVES: The purpose of this single center, prospective randomized controlled trial was to compare clinical outcomes between an ultrasound-guided greater occipital nerve block (GONB) at the C2 vertebral level versus landmark-based GONB at the superior nuchal line. METHODS: Patients with occipital neuralgia or cervicogenic headache were randomized to receive either a landmark-based GONB with sham ultrasound at the superior nuchal line or ultrasound-guided GONB at the C2 vertebral level with blinding of patients and data analysis investigators. Clinical outcomes were assessed at 30 minutes, 2 weeks, and 4 weeks postinjection. RESULTS: Thirty-two patients were recruited with 16 participants in each group. Despite randomization, the ultrasound-guided GONB group reported higher numeric rating scale (NRS) scores at baseline. Those in the ultrasound-guided GONB group had a significant decrease in NRS from baseline compared with the landmark-based GONB group at 30 minutes (change of NRS of 4.0 vs. 2.0) and 4-week time points (change of NRS of 2.5 vs. -0.5). Both groups were found to have significant decreases in Headache Impact Test-6. The ultrasound-guided GONB had significant improvements in NRS, severe headache days, and analgesic use at 4 weeks when compared with baseline. No serious adverse events occurred in either group. CONCLUSIONS: Ultrasound-guided GONBs may provide superior pain reduction at 4 weeks when compared with landmark-based GONBs for patients with occipital neuralgia or cervicogenic headache.

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation.

INTRODUCTION: The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. MATERIALS AND METHODS: Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. RESULTS: This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. CONCLUSIONS: The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.

The painful shoulder arthroplasty: appropriate work-up and review of interventional pain treatments.

Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty.

Skin Closure Technique and Postprocedural Pain after Spinal Cord Stimulator Implantation: A Retrospective Review.

Spinal cord and dorsal root ganglion stimulation are minimally invasive surgical techniques used to treat an array of chronic pain disorders. There is a paucity of data related to defining best practices in these specific patient populations, and historically, providers have relied on consensus committees to opine on the best techniques for patient safety and experience. The most efficacious mechanism of surgical closure-specifically a running suture closure compared to a surgical staple closure-is debated. A retrospective review of 155 patients implanted with either a spinal cord or dorsal root ganglion stimulator between 2017 and 2019 was undertaken to determine if the type of surgical closure was related to degree of postoperative surgical site discomfort. The primary outcome showed no statistically significant difference on postoperative pain scores between the suture (6.0 (IQR 5.0-8.0)) and staple (7.0 (IQR 5.0-8.0)) cohorts at postoperative day (POD) #1 (adjusted ß 0.17 (95% CI -0.61 to 0.95), P=0.670). This finding held for postoperative pain scores at POD #10 as well (staples (1.0 (IQR 0.0-4.0)) and suture (2.0 (IQR 0.0-5.0), adjusted ß -0.39 (95% CI -1.35 to 0.58), P=0.432)). A regression analysis was performed to identify secondary factors impacting postoperative pain scores. Higher preoperative pain score (ß 0.50 (95% CI 0.09 to 0.92), P=0.019) and female gender (ß 1.09 (95% CI 0.15 to 2.02), P=0.023) were predictive of higher incisional pain scores at POD#10. Increasing age was associated with decreased incisional pain scores at POD#10 (ß -0.06 (95% CI -0.09 to -0.03), P < 0.001). These findings are of interest to the pain practitioner and may be valuable in preoperative discussions with prospective patients.

Ultrasound-guided transversus abdominis plane block vs trigger point injections for chronic abdominal wall pain: a randomized clinical trial.

ABSTRACT: The primary aim of this randomized clinical trial is to investigate the effects of ultrasound-guided transversus abdominis plane (TAP) vs ultrasound-guided trigger point injections (TPIs) on numerical rating scale pain scores at month 3 follow-up in patients with a chronic abdominal wall pain. The primary outcome measure was the difference in mean numeric rating scale pain scores between the TAP and TPI groups at month 3 in an intent-to-treat (ITT) analysis. A total of 60 patients were randomized 1:1 to receive an ultrasound-guided TAP block (n = 30) or an ultrasound-guided TPI (n = 30). No significant group differences in baseline demographic or clinical characteristics were observed. The mean baseline pain score for the TAP and TPI groups was 5.5 and 4.7, respectively. In the ITT analysis at month 3, the between-group difference in pain scores was 1.7 (95% confidence interval, 0.3-3.0) favoring the TPI group. In a secondary per-protocol analysis, the between-group difference in pain scores was 1.8 (95% confidence interval, 0.4-3.2) favoring the TPI group. For the ITT and per-protocol analyses, the group differences in pain scores were consistent with a medium effect size. The main finding of this randomized clinical trial is that adults with chronic abdominal wall pain who received a TPI reported significantly lower pain scores at month 3 follow-up compared with patients who received a TAP block.

Current Perspectives on Spinal Cord Stimulation for the Treatment of Cancer Pain.

Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.

Current Evidence Lacking to Guide Clinical Practice for Spinal Cord Stimulation in the Treatment of Neuropathic Pain in Spinal Cord Injury: A Review of the Literature and a Proposal for Future Study.

BACKGROUND/OBJECTIVE: Chronic pain is commonly reported in individuals with spinal cord injuries (SCIs), with recent prevalence reported as high as 80%. Uncontrolled pain is known to decrease quality of life, attenuate mood, and impact sleep. Spinal cord stimulation (SCS) for the treatment of refractory pain was first used in the SCI population in 1972. To date there have been no randomized controlled trials examining the effect of SCS on neuropathic pain post-SCI. A literature review in 2009 identified 27 studies, the majority prior to 2000, that included at least 1 patient with SCI. Given the significant advancements in the field of SCS, this review examines the updated evidence of SCS for the treatment of neuropathic pain in individuals with SCI and provides guidance on future investigations. METHODS: MEDLINE and EMBASE databases were searched. All published reports, case series, and clinical trials reviewing SCS for neuropathic pain that included at least 1 individual with SCI were included. RESULTS: The initial search identified 376 reports, of which 22 met inclusion criteria, for a total of 69 patients. All reports were of very low quality. A majority of the reported patients were male, underwent tonic stimulation, and reportedly experienced improvement in pain and spasticity, with decreased use of pain medication. CONCLUSIONS: The synthesized findings from primarily case studies support the safety of SCS in SCI with the suggestion of potential pain relief benefit; however, data from low-quality studies are insufficient for informing clinical practice. A well-designed, prospective clinical trial is proposed to further investigate this indication.

Pain medicine fellow neuromodulation surgical skill assessment tool: a pilot.

OBJECTIVE: Spinal cord stimulation (SCS) is an evidence-based therapy for the treatment of refractory pain. Current American College of Graduate Medical Education requirements for pain medicine fellowship graduation include observation of five neuromodulation cases. Matriculating fellows have varying degrees of technical skill, training, and experience. The purpose of this study was to use an innovative skill-based assessment tool using the validated Zwisch scale to evaluate fellow surgical performance during SCS cases. DESIGN: Cross-sectional survey SETTING: Mayo Clinic, Rochester, Minnesota. SUBJECTS: Consultant faculty (10) in the Division of Pain Medicine and pain medicine fellows (5). METHODS: A list of faculty-driven neuromodulation surgical objectives was formed and a rubric was created that focused on technical approach, imaging, epidural access and wound closure. Consultants who perform surgical cases were instructed to use the Zwisch scale as a guide to evaluate fellow surgical performance during a neuromodulation case. Faculty and fellows were surveyed before and after implementation of the tool to determine their satisfaction with use of the skill assessment tool. RESULTS: The consultants reported they were more satisfied, consistent, and efficient with feedback provided to the trainee on every aspect of neuromodulation surgical cases. The improvement was most significant during the fellows' intraoperative skill assessment. The fellows indicated increased satisfaction, improved communication, and increased efficiency of feedback when the tool was utilized. The fellows reported greater intraoperative skill assessment and consistency of feedback provided. CONCLUSIONS: The diverse nature of primary specialty backgrounds observed in pain medicine fellowship training offers a unique opportunity to assess and improve fellow skill and surgical competence in the field of neuromodulation. Both faculty and fellows reported improved satisfaction, consistency and efficiency with feedback provided. Importantly, this pilot project observed that implementation of a skill assessment tool was beneficial for both the faculty and fellow as the feedback received was viewed as strongly beneficial to the educational experience.

High Cervical Intrathecal Targeted Drug Delivery: A Case Report of Refractory Oropharyngeal Cancer Pain.

INTRODUCTION: Some patients with head and neck cancers have pain refractory to aggressive multimodal therapies. Herein, we report the use of an intrathecal targeted drug delivery (TDD) system catheter tip placed at C1 for the treatment of recalcitrant oropharyngeal cancer pain. CASE REPORT: A patient with recurrent metastatic squamous cell tongue cancer reported severe pain not controlled despite high-dose opioids and nonopioid adjuvants. It was elected to proceed with an intrathecal TDD system with the catheter tip placed at the C1 level. After pump placement, we were able to decrease her daily oral morphine equivalents (OME) from nearly 1000 mg to 300 mg over the course of two months while titrating her TDD from 0.3 mg/day to 0.7 mg/day of intrathecal hydromorphone. Unfortunately, her improvement was limited secondary to aggressive cancer-directed treatments likely contributing to device infection and explant. CONCLUSIONS: In this patient, high cervical placement of an intrathecal TDD catheter was associated with a decrease in OME. While used in clinical practice on occasion, the use of high cervical TDD placement such as this implantable C1 intrathecal TDD system for cancer-associated pain is underreported in the literature. Further studies on this intervention within this challenging population are warranted.

Curing Opioid Toxicity with Intrathecal Targeted Drug Delivery.

Pain is one of the most feared symptoms that concern cancer patients and their families. Despite well-established guidelines set forth by the World Health Organization (WHO) on the treatment of cancer pain, nearly half of cancer patients report poorly controlled pain. One of the most serious side effects of systemic oral opioid use is neurotoxicity, which is characterized by altered mental status and systemic neurologic impairments. Treatment strategies are supportive in nature and focused on reducing or changing the offending opioid and correcting any metabolic deficiencies. Herein, we discuss a case of opioid-induced neurotoxicity treated with intrathecal targeted drug delivery (TDD). The timing and implementation of advanced therapies such as intrathecal TDD is not well delineated. More importantly, patients and their oncologic providers are often unaware of this useful tool in treating challenging cancer-associated pain and significantly minimizing systemic opioid side effects. To ensure that patients have comprehensive oncologic care, best-practice guidelines suggest involvement of an interdisciplinary team and coordinated care. Early referral to a pain and palliative specialist may allow for improved patient outcomes and removal of unnecessary barriers to optimal patient care.

Attitudes of Hospice Providers Regarding Intrathecal Targeted Drug Delivery for Patients With Cancer.

Pain is one of the most commonly experienced and feared symptoms faced by patients with a serious illness. For these patients, intrathecal drug delivery systems (IDDSs) provide greater potency and/or few systemic side effects. However, despite these benefits, the integration and management of IDDS for patients receiving hospice care has not been previous studied. An electronic, 18-question survey was sent to 200 hospice practitioners (physicians, nurse practitioners and nurses) in the state of Minnesota to explore their experience, confidence, and the perceived barriers to caring for patients with IDDS while being cared for on hospice. Providers were identified though mailing lists from the Minnesota Network of Hospice and Palliative Care organization. The survey was administered by the Mayo Clinic Survey Research Center with institutional review board approval. Slightly more than 50% of respondents have ever cared for a patient with an intrathecal pump. If a patient had a pump in place, only 28% of providers expressed confidence in managing their pain. Additionally, only 3 of 10 respondents felt that adjusting an intrathecal pump should be the first option when a patient with an IDDS in place had increased pain. Indeed, the vast majority (over 80%) of respondents preferred the use of systemic therapies for primary pain management. Access to IDDS vendors for changes/refills in the home is identified as another barrier with over 50% of respondents either unaware of an available vendor or reporting no vendor available. There are numerous self-reported barriers to ongoing use of IDDS with patients receiving hospice care.

Title: Quantifying the change of spasticity after intrathecal baclofen administration: A descriptive retrospective analysis.

OBJECTIVES: Exploratory research quantifying the change of spasticity among patients who underwent baclofen intrathecal drug delivery system (IDDS) implantation. PATIENTS AND METHODS: 88 patients with a baclofen IDDS were identified. Patient characteristics, spasticity scores pre/post intrathecal baclofen test dose, and IDDS perioperative implantation records were collected. The primary outcome was to quantify the extent to which there was a change in Modified Ashworth Scores (MAS) pre/post-intrathecal baclofen test dose administration. Secondary outcomes included the prevalence of perioperative IDDS implantation complications. RESULTS: The mean age at IDDS implant was 44.2 years (range, 19-71), and 62.5% were male. 45.5% had spasticity of spinal cord origin, 9% of cerebral origin, and 45.5% of other upper motor neuron dysfunction. Reduction of MAS in the spinal cord origin group was 2.6 (mean, 3.5 to 0.9), cerebral origin group was 2.9 (mean, 3.3 to 0.4), and other origin group was 2.5 (mean, 3.6 to 1.1). In all patients, post dural puncture headache was the most commonly reported complication at 22.7%. CONCLUSION: This report offers novel findings documenting a quantifiable change of at least two points on the MAS before and after intrathecal baclofen test dose as statistically significant and could prove to be useful information to enhance the decision making process to proceed with intrathecal baclofen beyond assessment of functional abilities.

Utilization of Leads After Permanent Implant in Spinal Cord Stimulator Systems.

OBJECTIVE: The goal of this study was to determine the frequency and clinical indications associated with implantation of single vs. dual percutaneous lead spinal cord stimulator (SCS) systems and to look further into how these leads are utilized for treatment. MATERIALS AND METHODS: A retrospective cohort analysis of all patients undergoing SCS implantation between January 2001 and December 2013 with a minimum of 2 years of clinical follow-up was performed. Number of trial leads and implanted leads was recorded. For patients with dual-lead systems, it was noted if and when the second lead was used, along with the clinical indication for lead activation. RESULTS: In the 259-patient cohort, 15.8% (n = 41) patients underwent placement of a single-lead system, 83.0% (n = 215) underwent placement of a dual-lead system, and 1.2% (n = 3) underwent placement of 3-lead systems. Placement of dual-lead systems was similar among all indication groups. Of those patients with a dual-lead system in place, 88.1% utilized both leads and average time to programming of the second lead was 2.3 months. The most common reason to activate the second lead was inadequate stimulation coverage. Five of the 41 patients with single-lead systems underwent an additional surgery to implant a second lead due to inadequate stimulation with 1 lead. CONCLUSIONS: To our knowledge this is the first descriptive analysis of the frequency of single- and dual-lead SCS systems. This report indicates that dual-lead systems are most often placed and both leads are required for optimal patient therapy.

Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study.

BACKGROUND: Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited. OBJECTIVE: To determine whether ultrasound can improve the ability of physicians in training (residents) to palpate the long head of the biceps tendon (LHBT) in the bicipital groove. DESIGN: Prospective study design. SETTING: Tertiary care center. PARTICIPANTS: Ten physical medicine and rehabilitation residents served as subjects. Exclusion criteria included the presence of any condition that precluded their ability to palpate. Three volunteers were used as models. Model exclusion criteria included anything that distorted normal shoulder anatomy or inhibited examiner palpation. Three investigators with experience performing diagnostic musculoskeletal ultrasound were used to confirm palpation attempts. METHODS: Subjects attempted to palpate the LHBT bilaterally in the bicipital groove of each model. Investigators assessed the accuracy of the palpation attempt using real-time ultrasonography. Subjects participated in a 30-minute ultrasound-assisted training session learning how to palpate the LHBT in the bicipital groove with ultrasound confirmation. After the ultrasound training session, subjects again attempted to palpate the LHBT in the bicipital groove of each model with investigator confirmation. MAIN OUTCOME MEASUREMENTS: LHBT palpation accuracy rates preintervention versus postintervention. RESULTS: Pretraining LHBT palpation accuracy was 20% (12/60 attempts). Post-ultrasound training session accuracy was 51.7% (31/60 attempts; P ≤ .001). CONCLUSIONS: Our findings demonstrate that palpation accuracy improves after ultrasound assisted LHBT palpation training. These data suggest that the use of ultrasound may be beneficial when teaching musculoskeletal palpation skills to health care professionals. LEVEL OF EVIDENCE: II.

Spinal Cord Stimulator Related Infections: Findings From a Multicenter Retrospective Analysis of 2737 Implants.

INTRODUCTION: Surgical site infection is a potential complication of spinal cord stimulator (SCS) implantation. Current understanding of the epidemiology, diagnosis, and treatment of these infections is based largely on small clinical studies, many of which are outdated. Evidence-based guidelines for management of SCS-related infections thus rely instead on expert opinion, case reports, and case series. In this study, we aim to provide a large scale retrospective study of infection management techniques specifically for SCS implantation. METHODS: A multicenter retrospective study of SCS implants performed over a seven-year period at 11 unique academic and non-academic institutions in the United States. All infections and related complications in this cohort were analyzed. RESULTS: Within our study of 2737 SCS implant procedures, we identified all procedures complicated by infection (2.45%). Localized incisional pain and wound erythema were the most common presenting signs. Laboratory studies were performed in the majority of patients, but an imaging study was performed in less than half of these patients. The most common causative organism was Staphylococcus aureus and the IPG pocket was the most common site of an SCS-related infection. Explantation was ultimately performed in 52 of the 67 patients (77.6%). Non-explantation salvage therapy was attempted in 24 patients and was successful in resolving the infection in 15 patients without removal of SCS hardware components. DISCUSSION: This study provides current data regarding SCS related infections, including incidence, diagnosis, and treatment.