Changeability of tissue's magnetic remanence after galvanic-magnetostimulation in upper-back pain treatment.

OBJECTIVE: Research was conducted on parametric profiles of healthy subjects and patients with cervico-brachial pain syndrome resulting from C4/5 and/or C5/6 discopathy, including magnetic remanence of tissues in marker points 1-12 (L+R) and functional parameters, and their subsequent change after treatment in group A, using method of push-pull galvanic magnetostimulation (GMT 2.0). DESIGN: GMT 2.0 device, comprised of one air solenoid and three galvanic solenoids in electrolytic tubs, was designed for push-pull magnetostimulation of the head, coupled with simultaneous stimulation of the limbs. SETTING: Clinical trial was conducted in Outpatient Private Clinic "VIS" under the auspices of Silesian Higher Medical School in Katowice, Poland. PATIENTS: 55 subjects participated in the study: control group K consisted of 23 healthy individuals, whereas 33 patients in group A were treated using GMT 2.0. INTERVENTION: Only patients in group A were treated with GMT 2.0 during 40-min sessions over a period of 10 days. MAIN OUTCOME MEASURES: Parametric profile of the patients was defined using various measurements: electronic SFTR test (C-Th-shoulders), HR, RR, BDI and VAS tests, magnetic remanence in marker points 1-12 (L+R) and blood parameters: HB, ER, CREA, BIL, K(+), Na(+), Cl(-) Fe(2+), Ca(2+) and Mg(2+). RESULTS: There was a significant reduction in pain (VAS), increase in the range of motion (SFTR), lower depression symptoms (BDI), slower heart rate (HR), lower blood pressure (RR), greater concentration of Mg(2+), K(+), Ca(2+)ions and reduction in the concentration of BIL, CREA Fe(2+) after GMT 2.0 treatment in group A. Evaluation of magnetic remanence in marker points M1-12 (L+R) initially showed higher values in group K, which after treatment were normalized to values similar to those in group K. CONCLUSION: GMT 2.0 treatment in group A resulted in normalization of magnetic remanence, synergically with increased range of motion (SFTR test), decreased HR and RR parameters, smaller depressive trends (BDI test), as well as increased ion levels (K(+), Mg(2+), Ca(2+)) and better functional parameters of kidneys and liver.

CAPACITIVE COUPLING ELECTRIC FIELDS IN THE TREATMENT OF VERTEBRAL COMPRESSION FRACTURES.

Positive effects of Capacitive Coupling Electric Field (CCEF) stimulation are described for several orthopedic indications such as the healing of recent fractures, non-unions and spinal fusion, due to the capacity to involve the up-regulation of osteopromotive factors. In vitro studies on MC3T3-E1 bone cells showed that CCEF acts opening the plasma membrane voltage gated calcium channels, thus increasing the cytosolic calcium concentration and the phospholipase A2 (PLA2) activity. Cytosolic calcium activates the calmodulin pathway, thus resulting in an up-regulated expression of osteogenic genes, such as transforming growth factor-ß superfamily genes (TGF-ß1, -ß2 -ß3, bone morphogenetic protein-2 and -4), fibroblast growth factor (FGF)-2, osteocalcin (BGP) and alkaline phosphatase (ALP). PLA2 acts increasing the synthesis of Prostaglandin E2 (PGE2), which promotes osteogenesis by raising the cellular L-ascorbic acid uptake through the membrane carrier sodium vitamin C transporter-2 (SVCT-2). In vivo, Brighton et al. in a castration-induced osteoporosis animal model, demonstrated that CCEF was able to restore bone mass/unit volume in the rat vertebral body. To investigate the role of CCEF stimulation in vertebral bone marrow edema (VBME) its percentage was assessed in 24 patients with 25 acute vertebral compression fractures (VCFs) conservatively treated with CCEF (group A) or without CCEF (group B) using serial MR imaging follow-up at 0, 30, 60, 90 days. Pain and quality of life were assessed by visual analog scale (VAS) and Oswestry Low Back Disability Index (ODI) in the same periods. At 90 day follow-up the complete resolution of VBME was found only in group A (p=0.0001). A significant improvement of VAS (p=0.007) and ODI (p=0.002) was also observed in group A. This preliminary observational study shows that patients treated with CCEF stimulation present an improvement of clinical symptoms with faster fracture healing and a complete VBME resolution.

Efficacy of gabapentin in the improvement of pruritus and quality of life of patients with notalgia paresthetica.

BACKGROUND: notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES: To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS: We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS: The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION: Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica.

Impact of osteopathic treatment on pain in adult patients with cystic fibrosis--a pilot randomized controlled study.

BACKGROUND: Pain is a common complication in patients with cystic fibrosis (CF) and is associated with shorter survival. We evaluated the impact of osteopathic manipulative treatment (OMT) on pain in adults with CF. METHODS: A pilot multicenter randomized controlled trial was conducted with three parallel arms: OMT (group A, 16 patients), sham OMT (sham treatment, group B, 8 patients) and no treatment (group C, 8 patients). Medical investigators and patients were double-blind to treatment for groups A and B, who received OMT or sham OMT monthly for 6 months. Pain was rated as a composite of its intensity and duration over the previous month. The evolution of chest/back pain after 6 months was compared between group A and groups B+C combined (control group). The evolution of cervical pain, headache and quality of life (QOL) were similarly evaluated. RESULTS: There was no statistically significant difference between the treatment and control groups in the decrease of chest/back pain (difference = -2.20 IC95% [-4.81; 0.42], p = 0.098); also, group A did not differ from group B. However, chest/back pain decreased more in groups A (p = 0.002) and B (p = 0.006) than in group C. Cervical pain, headache and QOL scores did not differ between the treatment and control groups. CONCLUSION: This pilot study demonstrated the feasibility of evaluating the efficacy of OMT to treat the pain of patients with CF. The lack of difference between the group treated with OMT and the control group may be due to the small number of patients included in this trial, which also precludes any definitive conclusion about the greater decrease of pain in patients receiving OMT or sham OMT than in those with no intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT01293019.

Efficacy of gabapentin in the improvement of pruritus and quality of life of patients with notalgia paresthetica

BACKGROUND: notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES: To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS: We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS: The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION: Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica. .

Screening of the spine in adolescents: inter- and intra-rater reliability and measurement error of commonly used clinical tests.

BACKGROUND: Evidence on the reliability of clinical tests used for the spinal screening of children and adolescents is currently lacking. The aim of this study was to determine the inter- and intra-rater reliability and measurement error of clinical tests commonly used when screening young spines. METHODS: Two experienced chiropractors independently assessed 111 adolescents aged 12-14 years who were recruited from a primary school in Denmark. A standardised examination protocol was used to test inter-rater reliability including tests for scoliosis, hypermobility, general mobility, inter-segmental mobility and end range pain in the spine. Seventy-five of the 111 subjects were re-examined after one to four hours to test intra-rater reliability. Percentage agreement and Cohen's Kappa were calculated for binary variables, and interclass correlation (ICC) and Bland-Altman plots with Limits of Agreement (LoA) were calculated for continuous measures. RESULTS: Inter-rater percentage agreement for binary data ranged from 59.5% to 100%. Kappa ranged from 0.06-1.00. Kappa ≥ 0.40 was seen for elbow, thumb, fifth finger and trunk/hip flexion hypermobility, pain response in inter-segmental mobility and end range pain in lumbar flexion and extension. For continuous data, ICCs ranged from 0.40-0.95. Only forward flexion as measured by finger-to-floor distance reached an acceptable ICC(≥ 0.75). Overall, results for intra-rater reliability were better than for inter-rater reliability but for both components, the LoA were quite wide compared with the range of assessments. CONCLUSION: Some clinical tests showed good, and some tests poor, reliability when applied in a spinal screening of adolescents. The results could probably be improved by additional training and further test standardization. This is the first step in evaluating the value of these tests for the spinal screening of adolescents. Future research should determine the association between these tests and current and/or future neck and back pain.

The spine in ß-thalassemia syndromes.

STUDY DESIGN: Literature review. OBJECTIVE: To present a comprehensive overview of spinal involvement in patients with ß-thalassemia, aiming to orient the spinal surgeon to these potentially disabling complications. SUMMARY OF BACKGROUND DATA: ß-thalassemia, an inherited disorder of hemoglobin synthesis, is the most common monogenetic disease worldwide. Patients with thalassemia major (TM) suffer a severe anemia that requires regular blood transfusions for survival and iron chelation therapy to control transfusional iron overload. Thalassemia intermedia is a phenotype of thalassemia with a milder course and anemia, wherein most patients remain transfusion independent. Spinal involvement related to disease course and treatment is common in patients with thalassemia syndromes, yet it has not been constructively reviewed in the literature. METHODS: Potentially relevant studies were identified from an electronic search of MEDLINE (1966 to the second week of May 2010). RESULTS: In patients with TM, genetic and acquired risk factors lead to osteoporosis, pathologic fractures of the spine, and back pain. Osteoporosis in TM patients is progressive; thus, early diagnosis and treatment are recommended. Bisphosphonates are relatively safe and effective in this patient population. Characteristic intervertebral disc degeneration is also seen in patients with TM who have evidence of severe iron overload or those who receive the subcutaneous iron chelator deferoxamine. Spinal asymmetry and overt scoliosis are common in patients with TM. The prognosis seems favorable, with many patients showing spontaneous resolution without the need for intervention. In patients with thalassemia intermedia, ineffective erythropoiesis drives extramedullary hematopoietic tissue formation, which is mostly evident on magnetic resonance imaging. Paraspinal involvement is of greatest concern because of the associated spinal cord compression. Several treatment options have been described, including transfusion therapy, laminectomy, radiotherapy, and the use of fetal hemoglobin-inducing agents that decrease the hematopoietic drive. CONCLUSION: Current knowledge supports that spinal involvement in patients with ß-thalassemia is common and diverse yet still requires further prospective evaluation.

Intradiscal electrothermal therapy for symptomatic internal disc disruption: 24-month results and predictors of clinical success.

OBJECT: Degeneration of the intervertebral disc can be the source of severe low-back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. This study was undertaken in the neurosurgical setting to evaluate 24-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET. METHODS: Using MR imaging and discography findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment, and were followed up for 24 months. Outcomes included assessments of back pain severity based on an 11-point numeric scale and back function based on the Oswestry Disability Index. The Prolo scale was applied to determine economic and functional status at 24 months. RESULTS: There was an average 68 and 66% improvement in back pain and function, respectively, between pretreatment and 24 months after treatment (p < 0.0001 for both comparisons). A maximum score of 5 on the Prolo scale for economic and functional status was achieved in 63 and 22% of patients, respectively. The global clinical success rate was 78% (39 of 50 patients) based on no reoperations at the affected level due to persistent symptoms, with a >or= 2-point improvement in pain severity and a >or= 15-point improvement in back function. Predictors of 24-month clinical success included discographic concordance (p < 0.0001), a high-intensity zone on MR imaging (p = 0.0003), low Pfirrmann grade (p = 0.0002), and more extensive anulus coverage (p < 0.0001). There were no procedure-related adverse events. CONCLUSIONS: The findings of this study suggest that durable clinical improvements can be realized after IDET in highly select surgical candidates with mild disc degeneration, confirmatory imaging evidence of anular disruption, and highly concordant pain provocation on low-pressure discography.

Spinal cord stimulation for failed back surgery syndrome and other disorders.

Chronic pain is a complex condition that requires a multi-disciplinary approach to management. Spinal cord stimulation (SCS) has evolved into a relatively easily implemented, reversible technique with low morbidity for the management of chronic, intractable pain in selected patients. Percutaneous placement of electrode arrays, under local anaesthesia. supported by programmable, implanted electronics has been a major technical advance. Multicenter prospective studies were conducted and demonstrated that SCS. as a neuromodulation procedure, is indeed a superior method for treatment of chronic pain if the patients are selected with caution and a proper strategy. Future development of innovative electrodes and pulse generation systems will continue to improve this therapy.

Chronic back pain is associated with decreased prefrontal and thalamic gray matter density.

The role of the brain in chronic pain conditions remains speculative. We compared brain morphology of 26 chronic back pain (CBP) patients to matched control subjects, using magnetic resonance imaging brain scan data and automated analysis techniques. CBP patients were divided into neuropathic, exhibiting pain because of sciatic nerve damage, and non-neuropathic groups. Pain-related characteristics were correlated to morphometric measures. Neocortical gray matter volume was compared after skull normalization. Patients with CBP showed 5-11% less neocortical gray matter volume than control subjects. The magnitude of this decrease is equivalent to the gray matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm3 loss of gray matter for every year of chronic pain. Regional gray matter density in 17 CBP patients was compared with matched controls using voxel-based morphometry and nonparametric statistics. Gray matter density was reduced in bilateral dorsolateral prefrontal cortex and right thalamus and was strongly related to pain characteristics in a pattern distinct for neuropathic and non-neuropathic CBP. Our results imply that CBP is accompanied by brain atrophy and suggest that the pathophysiology of chronic pain includes thalamocortical processes.

Efficacy and tolerance of Harpagophytum extract LI 174 in patients with chronic non-radicular back pain.

The aim of this open, multicentre study was to evaluate the clinical effectiveness and tolerance of the Devil's Claw extract LI 174 in patients suffering from non-radicular back pain over a period of at least 6 months. A total of 130 patients were treated twice a day with tablets containing 480 mg LI 174. The treatment lasted for 8 weeks. The effectiveness was judged according to the Multidimensional Pain Scale (MPS), Arhus back pain index and to parameters evaluating the mobility of the lumbar spine (finger-floor distance, Schober's sign). Data from 117 patients were evaluated for efficacy. The results showed a significant improvement of pain symptoms and mobility of the affected sections of the patient's spine in the course of treatment. No serious side effects were observed. In view of the excellent compliance and tolerability the investigated extract appears to be an effective plant alternative for the treatment of chronic back pain. However, further studies will be needed to clarify the therapeutic value of this plant remedy.

Innervation of the human costovertebral joint: implications for clinical back pain syndromes.

BACKGROUND: The diagnosis of pain in the upper back, shoulder, chest, and arm is often made with considerable confusion and may be accompanied by needless expense and suffering by the patient. Despite the paucity of evidence concerning the tissues and mechanisms responsible for interscapular and atypical chest pain or "pseudo-angina," practitioners of manual therapy maintain that manipulation of the costovertebral elements and associated soft tissues may be helpful in the treatment of these painful conditions. OBJECTIVE: We have examined the costovertebral complex in humans with respect to the presence of immune-like reactivity to neurofilament protein and the neuropeptide substance P and calcitonin gene-related peptide, markers that reveal the presence of axons in peripheral tissues. DESIGN: Human costovertebral complexes obtained at autopsy were processed with standard histologic examination and immunocytochemical methods to detect the presence of neurofilaments, substance P, and calcitonin gene-related peptide. MAIN OUTCOME MEASURES: Outcomes were descriptive and did not require statistical methods. RESULTS: All costovertebral joints contained innervation within the anterior capsule and synovial tissues. In 4 separate cases, the costovertebral joints contained large intraarticular synovial inclusions or "meniscoids" found to contain small bundles of axons with immune-like reactivity to substance P. Axon bundles were identified in serial section with monoclonal antibodies to neurofilaments as well as with urea-silver nitrate staining. CONCLUSIONS: The costovertebral joint has been considered a candidate for producing back pain and/or pseudo-angina that may be ameliorated by spinal manipulation. This study has demonstrated that the costovertebral joint has the requisite innervation for pain production in a similar manner to other joints of the spinal column.

Rheumatic manifestations of neurologic and psychiatric diseases.

Rheumatic diseases have not proved to be more prevalent among neurologic or psychiatric patients than in the general population, except for osteoarthritis in some chronic disabling neurologic conditions (poliomyelitis, spinal cord injury). Some neurologic entities with relevant musculoskeletal manifestations are described here. The lower prevalence of rheumatoid arthritis in schizophrenia patients is mentioned, and a brief description is presented of somatoform disorders that may confound diagnosis with rheumatic diseases. Factitious disorders and malingering are frequently presented with rheumatic complaints such as low back pain and may have an important impact on the costs associated with the disease. Finally, some of the immune system abnormalities described in major depression and schizophrenia are mentioned with a clear reference to the growing field of psychoneuroimmunology. This paper will not address the issue of neurologic or psychiatric manifestations of rheumatic diseases.

Back pain after epidural anesthesia with chloroprocaine.

BACKGROUND: Chloroprocaine has been associated with severe back pain after epidural anesthesia. Factors proposed to contribute to this problem are: 1) the preservative disodium ethylenediaminetetraacetic acid (EDTA), 2) large volumes of chloroprocaine, 3) low pH of chloroprocaine, and 4) local infiltration with chloroprocaine. METHODS: Using a prospective, balanced, randomized study design, 100 patients aged 18-65 yr who were undergoing outpatient knee surgery during continuous epidural anesthesia received one of five local anesthetics (all containing epinephrine 1:200,000). Group I received a bolus of 30 ml 2% lidocaine, followed by 10 ml every 45 min. Group II received 15 ml of 3% chloroprocaine (containing EDTA), plus 5 ml every 45 min. Group III received 30 ml of 3% chloroprocaine plus 10 ml every 45 min. Group IV received 30 ml of 3% chloroprocaine (containing metabisulfite as the preservative but no EDTA) plus 10 ml every 45 min. Group V received 30 ml of 3% chloroprocaine with the pH adjusted to 7.3, plus 10 ml every 45 min. After the anesthesia dissipated and before any analgesic agents were given, the patients were asked to rank maximum knee and back pain on a visual analog scale (0-10) and to give a description of back pain. A telephone interview was conducted 24 h after surgery to determine if back pain returned. Back pain scoring was assessed using a verbal analog scale. RESULTS: After dissipation of anesthesia, the back pain reported by patients fell into two distinct categories. Type 1 pain was described commonly as superficial and localized to the site of needle insertion. There was no difference among groups in incidence of type 1 pain. Type 2 pain was described as deep, aching, burning, and poorly localized in the lumbar region (5% of the patients in group I, 10% in groups II and IV, 50% in group III, and 25% in group V). The incidence of type 2 pain was significantly greater in group III than in groups I, II, or IV. Group III also had a significantly greater mean visual analog scale pain score (types 1 and 2) than all other groups. CONCLUSIONS: Large doses (> or = 40 ml) of chloroprocaine containing EDTA resulted in a greater incidence of deep burning lumbar back pain. Using 25 ml or less of the same solution resulted in an incidence of both types 1 and 2 postepidural anesthesia back pain similar to that in the lidocaine control group.

The pathoanatomy and clinical significance of the sacroiliac joints.

The sacroiliac joint has a unique developmental anatomy which is responsible for an unusual and underdeveloped iliac cartilage surface. This surface tends to undergo premature degenerative change, which might be a factor in the pathogenesis of mechanical low back pain.

Spinal cord stimulation in 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation.

A total of 112 patients with epi-/intradural fibrosis following operation for lumbar disc herniation were treated by spinal cord stimulation. Lumbosacral spinal fibrosis is seen particularly often after extensive and repeated operations. Radicular pain responds better to stimulation than back pain. A favourable long-term effect on radicular pain has been observed in 67% of patients treated by epidural implantation, the corresponding average follow-up period being 4 1/2 years. 40% of these patients needed less analgesics after the operation, while 25% of them showed an improved fitness for work. Among about 5,000 patients who underwent surgical treatment for lumbar disc herniation, an indication for spinal cord stimulation was found in 1.5%. By comparison, the frequency of the "last resort" procedure of microsurgical cordotomy was 0.3%. We no longer use other ablative methods like extirpation of spinal ganglia.

Facet syndrome: clinical signs, symptoms, diagnosis, and treatment.

Low back pain is a major health problem in the United States today. Nearly 80% of Americans experience low back pain during their lifetime, with facet syndrome accounting for a large percentage of these symptoms. A recent study on low back pain showed involvement of one or more facet joints in 79% of the patients studied, while ruptured disc involvement was present in only 1%. This report investigates facet syndrome, its anatomy, etiology, clinical signs and symptoms, diagnosis, and various methods of treatment and patient management.

Low back disorders: conservative management.

Painful disorders of the low back may arise from a large variety of mechanisms and there is no simple, single solution to them. They have a great social and economic cost in industrialized countries. The major syndromes of low back pain and sciatica are reviewed, including myofascial pain syndromes, disc herniations, radiculopathies, spinal stenosis and facet syndromes. Non-operative management is reviewed, including bed rest, medications, traction, manipulation, external supports, physical modalities, therapeutic exercise, trigger point injection and chemonucleolysis. Prevention should become the main goal of physicians dealing with this multifaceted problem.