Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury.

Objective: Prolonged mental fatigue and cognitive impairments are common after a mild traumatic brain injury (TBI). This sets limits for rehabilitation and for regaining the capacity for work and participation in social life.Method: This follow-up study, over a period of approximately 5.5 years was designed to evaluate the effect and safety of methylphenidate treatment for mental fatigue after a mild TBI. A comparison was made between those who had continued, and those who had discontinued the treatment. The effect was also evaluated after a four-week treatment break.Results: Significant improvement in mental fatigue, depression, and anxiety for the group treated with methylphenidate (p < .001) was found, while no significant change was found for the group without methylphenidate. The methylphenidate treatment group also improved their processing speed (p = .008). Withdrawal produced a pronounced and significant deterioration in mental fatigue, depression, and anxiety and a slower processing speed. This indicates that the methylphenidate effect is reversible if discontinued and that continued methylphenidate treatment can be a prerequisite for long-term improvement. The effect was found to be stable and safe over the years.Conclusion: We suggest methylphenidate to be a possible treatment option for patients with post-TBI symptoms including mental fatigue and cognitive symptoms.

Pharmacological treatment patterns in neuropathic pain--lessons from Swedish administrative registries.

OBJECTIVE: To explore the treatment patterns of patients with a diagnosis related to chronic pain (DRCP) initiating pharmacological treatment indicated for neuropathic pain (NeuP: tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants). DESIGN: Retrospective study on administrative registers. SETTING: General population in Western Sweden (one sixth of the country). SUBJECTS: All patients with a DRCP (N = 840,000) in years 2004-2009. OUTCOME MEASURES: Treatment sequence, continuation, switching, and comedication. RESULTS: In total, 22,997 patients with a first NeuP in 2007 or 2008 were identified, out of which 2% also had epilepsy and 39% had a mood disorder. The remaining 13,749 patients were assumed to be treated for neuropathic pain, out of which 16% had a neuropathy diagnosis, 18% had a mixed pain diagnosis, and the remaining 66% had another DRCP. The most common first prescription was amitriptyline (40%) followed by pregabalin (22%) and gabapentin (19%). More than half had discontinued treatment after 3 months, and 60-70% at 6 months. Seven percent received another NeuP drug within 6 months of the discontinuation of their first NeuP treatment, 11% had another analgesic and 22% had a prescription indicating psychiatric comorbidity (selective serotonin reuptake inhibitors or benzodiazepine). CONCLUSIONS: Treatment initiation of currently available drugs indicated for neuropathic pain less frequently lead to long-term treatment in clinical practice compared with clinical trial, and few try more than one drug. We suggest our findings to be indications of a need for better routines in diagnosing patients to ascertain optimal treatment and follow-up.

Antihypertensive effect of low-frequency transcutaneous electrical nerve stimulation (TENS) in comparison with drug treatment.

Hypertension is a major risk factor for vascular disease, yet blood pressure (BP) control is unsatisfactory low, partly due to side-effects. Transcutaneous electrical nerve stimulation (TENS) is well tolerated and studies have demonstrated BP reduction. In this study, we compared the BP lowering effect of 2.5 mg felodipin once daily with 30 min of bidaily low-frequency TENS in 32 adult hypertensive subjects (mean office BP 152.7/90.0 mmHg) in a randomized, crossover design. Office BP and 24-h ambulatory BP monitoring (ABPM) were performed at baseline and at the end of each 4-week treatment and washout period. Felodipin reduced office BP by 10/6 mmHg (p <0.001 respectively) and after washout BP rose to a level still significantly lower than at baseline. TENS reduced office BP by 5/1.5 mmHg (p <0.01, ns). After TENS washout, BP was further reduced and significantly lower than at baseline, but at levels similar to BP after felodipin washout and therefore reasonably caused by factors other than the treatment per se. ABPM revealed a significant systolic reduction of 3 mmHg by felodipin, but no significant changes were noted after TENS. We conclude that our study does not present any solid evidence of BP reduction of TENS.

[Mental fatigue - possible explanations, diagnostic methods and possible treatments]. / Hjärntrötthet ­ ett osynligt gissel.

Mental fatigue or brain fatigue is a pathological and disabling symptom with diminished mental energy. It can be a long-lasting consequence after trauma or disease affecting the brain. The person can do most things in the moment and can be perceived as completely healthy, but the mental energy is insufficient over time and affects the ability to work and participate in social activities. After a conversation, for example, the person can be completely drained of energy and the recovery time is disproportionally long. Here we describe the phenomenon of mental fatigue, provide an explanatory model for how the condition can arise, point out diagnostic methods and possible treatments, which are currently in the research stage but may be implemented in healthcare within the foreseeable future.

Multidimensional health changes after a multimodal pain rehabilitation program: a registry-based study.

INTRODUCTION: Chronic pain is treated with multimodal rehabilitation programs, targeting improvement in several health aspects. These treatments must be evaluated multidimensionally, which is a methodological challenge. OBJECTIVES: This study investigated factors (demographic, pain-related, and individual- vs group-based treatment) predicting successful outcomes after multimodal pain rehabilitation programs. METHODS: Data from 3 outpatient clinics were retrieved from the Swedish Quality Registry for Pain Rehabilitation, for 314 patients (218 women). Outcome variables were dichotomized as binary change (improved or not improved) based on clinical thresholds. Total improvement grouped outcomes into 0 to 2, 3 to 4, and 5 to 6 improved variables. Binary logistic regression analyses investigated the association between the baseline predictors and change variables. RESULTS: Patients improving after treatment ranged from 34% (pain intensity) to 80% (depression) for women and 34% to 76% for men, respectively. Total improvement outcome was consistent (after treatment and 1 year) with 28% of patients improving on 5 to 6 outcomes. The baseline predictor related to most improved outcomes was pain intensity, with positive correlation to improvement in pain intensity (P < 0.001) and negative correlation with improvements in anxiety (P = 0.075) and depression (P = 0.002). Individual-based treatment, compared with group-based treatment, was associated with improvement in pain intensity (P = 0.008). CONCLUSIONS: About a third of patients improved in several outcomes by the end of a multimodal program, with most improvement for depression and least for pain intensity. Generally, patients with more severe health status at baseline improve most directly after treatment, but these findings could not suggest treatment adjustments that would improve overall success rates.

Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after hysteroscopy: a randomized controlled study.

OBJECTIVE: To compare the time spent in the Post-Anesthesia Care Unit (PACU) and the pain-relieving effects of treatment with high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) opioids after hysteroscopy. METHODS: All patients who postoperatively reported a visual analogue scale (VAS) pain score of ≥3 were included in the study. TENS treatment was given with a stimulus intensity between 40 and 60 mA for 1 minute and repeated once if there was insufficient pain relief. In the opioid group, a fractionated dose of 5 mg morphine was administered. If the patient reported insufficient pain relief after the assigned treatment, the patient was reassigned to the other treatment group. RESULTS: Seventy-four women were randomized to TENS (n=38) or IV opioids (n=36) for treatment. Both groups reported significant pain relief after discharge from the PACU, with a decrease of VAS scores from 5.6 to 1.4 in the TENS group (P<0.001) and 5.1 to 1.3 in the opioid group (P<0.001). There were no significant differences between the groups. When only the responders in both groups, i.e., patients with VAS scores of <3 on respectively assigned treatments, were compared, the TENS responders (n=22) were found to have spent a significantly shorter time in the PACU (91 vs. 69 minutes, P=0.013) compared to the opioid responders (n=20). CONCLUSION: Using TENS as first line of pain relief may reduce the need for postoperative opioids. In addition, TENS appears preferable as the first line of treatment due to its association with a shorter time spent in the PACU if the patient responds to the treatment. TRIAL REGISTRATION: Västra Götalandsregionen Identifier: 211261.

Interference of transcutaneous electrical nerve stimulation with permanent ventricular stimulation: a new clinical problem?

AIMS: To assess the compatibility of thoracic TENS and permanent PM treatment and to identify any signs of interference of TENS with the PM function. METHODS AND RESULTS: Twenty-seven patients treated with PM were tested. Transcutaneous electric nerve stimulation electrodes were placed above each mamilla, and the stimulation intensity was increased to the maximum level tolerated for 30 s or until electrocardiogram revealed signs of interference. Transcutaneous electric nerve stimulation of 2 and 80 Hz was tested with the PM ventricular sensing level set to the clinically chosen level as well as to maximal sensitivity. Interference was detected in 22 of 27 patients (81%). Low-frequency (2 Hz) stimulation was more associated with PM interference (52% at normal vs. 81% at maximal ventricular sensitivity) than high-frequency (80 Hz) stimulation (33% at normal vs. 63% at maximal ventricular sensitivity); although the differences were not statistically significant. CONCLUSION: Transcutaneous electric nerve stimulation frequently induces inhibition of the PM function already at the clinically set ventricular sensitivity. Therefore, individual testing is warranted before TENS treatment is considered in patients with a PM. A test protocol for TENS and PM interaction is proposed.

Risk of interference from transcutaneous electrical nerve stimulation on the sensing function of implantable defibrillators.

BACKGROUND: The use of transcutaneous electrical nerve stimulation (TENS) for pain relief is increasing. At the same time the implantable cardioverter defibrillator (ICD) is a routine treatment for malignant tachyarrhythmias. Today patients often need devices for more than one condition, and consideration must be given to the interaction between them. We studied the risk of interference between TENS and the ICD function. METHODS AND RESULTS: Thirty patients who had received an ICD underwent a test protocol including TENS at the mammilla and hip levels, at two energy levels, and at the highest comfortable stimulation level. The effects of TENS on the electrocardiogram lead II, intracardiac electrograms, and the ICD marker channels were analyzed. Disturbance from TENS on the sensing function was seen at all stimulation attempts. Interference between the systems was observed in 16 patients. In eight patients (27%) the interpretation was VT/VF and in 14 patients (47%) as ventricular premature extra beats. Other kinds of interactions were seen in five patients (16%). Each patient could have more than one kind of interference. CONCLUSIONS: Noise reversion and undersensing might prevent the ICD from delivering shock when it should and the interpretation as VT/VF could result in inappropriate shocks. Because of the potentially serious consequences of interference we do not recommend the use of TENS in patients with ICD.

Effects of high-frequency, high-intensity transcutaneous electrical nerve stimulation versus intravenous opioids for pain relief after gynecologic laparoscopic surgery: a randomized controlled study.

BACKGROUND: The aim of the study was to compare the pain relieving effect and the time spent in the recovery unit after treatment with high frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) or intravenous (IV) opioids after gynecologic laparoscopic surgery. METHODS: All patients who postoperatively reported visual analogue scale (VAS) pain score ≥ 3 were consecutively included in the study. The TENS treatment was given with a stimulus intensity between 40-60 mA during 1 minute, repeated once if insufficient pain relief. In the opioid group, a maximum dose of 10 mg morphine was given IV. If the patient reported insufficient pain relief (VAS ≥ 3) on the assigned treatment, the patient crossed over to the other treatment group. RESULTS: Ninety-three women were randomized to TENS (n = 47) or IV opioids (n = 46). Both groups reported significant pain relief at leave from the recovery unit (TENS group: VAS 5.4 to 1.0, P < 0.001; IV opioid group: VAS 5.2 to 1.1, P < 0.001) with no differences between the groups. When only responders, i.e. patients with VAS < 3 after assigned treatment, were compared the TENS responders spent significantly shorter time in the recovery unit (90 vs. 122 minutes, P = 0.008) compared to the responders in the opioid group. CONCLUSIONS: TENS and IV opioids are both effective treatments for pain relief after gynecologic laparoscopic surgery. TENS seems to be preferable for first choice of treatment as the treatment is associated with shorter time spent in recovery unit if the patient responds to the treatment.

Vulnerability and Resilience in Patients with Chronic Pain in Occupational Healthcare: A Pilot Study with a Patient-Centered Approach.

OBJECTIVES: The aim of this pilot study was to describe vulnerability and resilience and possible subgroups in patients with chronic work related musculoskeletal pain in occupational healthcare. A second aim was to evaluate a patient-centered approach. METHODS: This study was based on consecutive patients with chronic pain, seen by the same physician and sick-listed full or part time three months or longer. They were included during a period of three months. Patient reported outcome measures (PROM) were administered at baseline and at follow-up after 8 months. A patient-centered approach was applied where the patient's whole situation was taken into account. RESULTS: A dominance of an insecure dismissing attachment pattern and a subnormal sense of coherence (SOC) was reported both at baseline and at follow-up. The patients (n=38) reported significant improvement of pain severity (p=0.01), pain interference (p=0.001), life control (p=0.01), affective distress (p=0.02), and dysfunction (p=0.001) on the multidimensional pain inventory (MPI) and fewer patients were sick-listed full time at follow-up (13 patients versus 21). By means of multivariate data analyses this change in MPI was confirmed and was also correlated with a significant increase in health related quality of life (HRQoL). Moreover subgroups with different outcome at follow-up were identified according to attachment pattern and subgroups on MPI. CONCLUSION: A patient-centered approach may be of value for patients with chronic pain in occupational healthcare, improving pain and dysfunction. Patients with chronic pain are a heterogeneous group where outcome of treatment might be influenced by individual resilience and/or vulnerability.

Determining the Feasibility of Spinal Cord Neuromodulation for the Treatment of Chronic Systolic Heart Failure: The DEFEAT-HF Study.

OBJECTIVES: The primary objective of the study was a change in left ventricular end-systolic volume index (LVESVi) from baseline to 6 months of spinal cord stimulation (SCS) therapy in the treatment arm compared to the control arm as measured by echocardiography. Secondary objectives were changes in peak oxygen uptake and N-terminal pro-B-type natriuretic peptide (NT-proBNP) between the treatment arm and control arm from baseline through 6 months. BACKGROUND: Abnormal neurohormonal activation is often responsible for progression of heart failure (HF). Treatment has often included drug therapy to modulate the neurohormonal axis. The purpose of the DEFEAT-HF (Determining the Feasibility of Spinal Cord Neuromodulation for the Treatment of Chronic Heart Failure) clinical study was to evaluate whether direct modulation of the nervous system through SCS improved HF metrics, including heart size, biomarkers, functional capacity, and symptoms. METHODS: The DEFEAT-HF study was a prospective, multicenter randomized (3:2), parallel, single-blind, controlled study to investigate whether SCS was a feasible therapy for the treatment of systolic HF for patients with New York Heart Association functional class III HF, left ventricular ejection fraction (LVEF) ≤35%, QRS duration <120 ms, and left ventricular end-diastolic dimension ≥55 mm. The primary objective of the DEFEAT-HF study was to evaluate the reduction in LVESVi after 6 months of SCS therapy in the treatment arm compared to the control arm. RESULTS: In total, 81 patients were enrolled, with 66 successfully randomized and implanted with the SCS device system. Seventy-six percent (50 of 66) had an implantable cardioverter-defibrillator at the baseline visit. Among randomized patients, the mean age was 61 years, 79% were male, mean LVEF was 27%, and mean QRS duration was 105 ms. The change in LVESVi over 6 months was not significantly different between randomization arms (SCS OFF: -2.2 [95% confidence interval: -9.1 to 4.6] vs. SCS ON: 2.1 [95% confidence interval: -2.7 to 6.9]; p = 0.30). Analyses of secondary endpoints for the study were also not significantly different. CONCLUSIONS: The present study does not provide evidence to support a meaningful change in clinical outcomes for HF patients receiving SCS. (Determining the Feasibility of Spinal Cord Neuromodulation for the Treatment of Chronic Heart Failure [DEFEAT-HF]; NCT01112579).

The analgesic effect of transcutaneous electrical nerve stimulation (TNS) in patients with rheumatoid arthritis. A comparative study of different pulse patterns.

Transcutaneous electrical nerve stimulation (TNS) was used on 20 patients with severe wrist pain due to rheumatoid arthritis. Three different stimulation frequencies were used: high 70 Hz stimulation (70 TNS), low frequency 3 Hz stimulation (3 TNS) and brief trains of stimuli with an internal frequency of 70 Hz and with a repetition rate of 3 Hz (3-70 TNS). The analgesic effect was evaluated on the patient's own estimate of pain relief and by means of a loading test in which the length of time the patient could hold a weight before and after TNS was used. The loading test and the patients' own estimate of pain relief corresponded well. After 70 TNS, 18 patients could double their loading time. The corresponding figure for 3-70 TNS was 16 patients and for 3 TNS 5 patients. The average duration of pain relief after cessation of stimulation was 18 h for 70 TNS and 15 h for 3-70 TNS, while those who responded to 3 TNS experienced pain relief for only 4 h on average.

The effect of transcutaneous electrical nerve stimulation (TENS) on catecholamine metabolism during pacing-induced angina pectoris and the influence of naloxone.

Two invasive studies (invasive study I and invasive study II) showed positive effects of transcutaneous electrical nerve stimulation (TENS) in pacing-induced angina pectoris in terms of increased tolerance to pacing, improved lactate metabolism and less anginal pain. Invasive study I demonstrated a decrease in left ventricular afterload by TENS treatment as reflected by a fall in systolic blood pressure, and this fact was thought to be explained by reduced sympathetic activity since arterial levels of epinephrine and norepinephrine dropped during TENS in TENS responders. In invasive study II, the influence of naloxone on the effects of TENS in pacing-induced angina pectoris was studied in 11 patients with severe coronary artery disease. The patients were catheterized and treated with TENS on 2 occasions; one with a single intravenous (i.v.) dose of saline as placebo and one with a single i.v. dose of 50 mg naloxone, double-blind, in random order. Treatment with TENS increased tolerance to pacing (P less than 0.01 with placebo and P less than 0.01 with naloxone, respectively) and improved lactate metabolism (P less than 0.05 with placebo and P less than 0.01 with naloxone, respectively). The positive effects of TENS were thus reproducible and not reversed by single i.v. doses of naloxone. The results of this study indicate that the effects of TENS on the heart are not mediated by beta-endorphin but do not exclude activation of more short-acting opioids like delta or kappa receptor agonists (met-enkephalin and/or dynorphin) since naloxone has a low affinity for these receptors. It is also possible that non-opioid mechanisms are of importance.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcutaneous electrical nerve stimulation (TENS) in angina pectoris.

The aim of this study was to determine the efficacy of transcutaneous electrical nerve stimulation (TENS) in the treatment of chronic stable severe angina pectoris. In a short-term study the effect of TENS was studied in 10 male patients with angina pectoris (functional class III and IV). All patients had previously been stabilized on long-term maximal oral treatment. The effects of the treatment were measured by means of repeated bicycle ergometer tests. All patients had an increased working capacity (16-85%), decreased ST segment depression and reduced recovery time during TENS. No adverse effects were observed. A long-term study of TENS on similarly selected patients showed beneficial effects in terms of pain reduction, reduced frequency of anginal attacks, increased physical activity and increased working capacity during bicycle ergometer tests. An invasive study was carried out with respect to systemic and coronary hemodynamics and myocardial metabolism during pacing provoked myocardial ischemia in 13 patients. The results showed that TENS led to an increased tolerance to pacing, improved lactate metabolism, less pronounced ST segment depression. A drop in systolic blood pressure during TENS treatment at identical pacing rates indicated a decreased afterload. An increased coronary flow to ischemic areas in the myocardium was supported by the fact that the rate pressure product during anginal pain increased during TENS.

Pain as presenting symptom in Lyme neuroborreliosis.

Neurogenic pain with radiculitis is often the starting symptom in adult patients with tick-borne Lyme neuroborreliosis and in some cases the only clinical manifestation. Cranial paresis and other neurologic signs usually occur after the onset of pain. The present paper describes four patients who had severe pain as the main presenting symptom of Lyme neuroborreliosis. Opioids had good short-term effect in two of the cases. Oral doxycycline treatment was used successfully to eliminate the infection.

Temporary cessation of spinal cord stimulation in angina pectoris-effects on symptoms and evaluation of long-term effect determinants.

BACKGROUND: Spinal cord stimulation (SCS) has been used since 1985 for patients with refractory angina pectoris. Spinal cord stimulation has anti-ischaemic effects and reduces angina effectively. After long-term treatment, temporary cessation of stimulation may occur due to SCS battery depletion or electrode fracture. The aim of the present study was to assess anginal symptoms and functional status during SCS dysfunction and after its restitution. DESIGN: A prospective follow-up study of angina patients treated with SCS, where temporary SCS dysfunction had occurred. METHODS: Thirty-two patients treated with SCS for angina pectoris over 65 months, on average (range 14-181 months), were included. Complete stimulator dysfunction had occurred due to battery depletion (n=25) or electrode fracture (n=7). The number of anginal attacks and the amount of short-acting nitrates consumed were assessed during dysfunction and after restitution of SCS function. The Seattle Angina Questionnaire (SAQ) was used to assess functional status. RESULTS: The anginal frequency increased during dysfunction (18.9 per week) and decreased after restitution of SCS function (7.6 episodes per week; p<0.001). The consumption of short-acting nitrates decreased as well (21.7 versus 7.1 tablets per week; p<0.01). The functional status according to the SAQ also improved with regard to anginal stability, anginal frequency, and disease perception. No evidence of tolerance development to SCS was found. CONCLUSION: This study indicates that SCS relieves angina effectively also after long-term treatment, without development of tolerance. The findings suggest that mechanisms other than placebo and spontaneous variation of symptoms are responsible for the improvement in angina during SCS.