The rise and fall of mandrake in medicine.

ETHNOPHARMACOLOGICAL RELEVANCE: Mandrake (Mandragora sp.) is one of the most famous medicinal plants. It has been in continuous medical use throughout written history and is still in use today in popular medicine. AIM OF THE STUDY: Mandrake derived drugs once played an important role in medicine and in magical practices. Today, the role of mandrake in popular medicine is marginal. However, natural products present in mandrake such as atropine and scopolamine, as well as their semi synthetic derivatives continue to hold and important role in medicine. Here we aim to trace the development of historical rationales and scientific events that led to the abandonment of mandrake as a medicine. MATERIALS AND METHODS: We review the medicinal uses of mandrake drugs since antiquity in an attempt to pinpoint use patterns that were popular in certain periods of time and others that are more general. We compare the uses from the native territories to those from regions where the plant got introduced and use literature reporting mandrake's chemistry and pharmacology in order to explain the diachronic changes of use patterns. RESULTS AND CONCLUSION: We found information about 88 different medicinal uses for mandrake, grouped into 39 conditions. According to the number of different medicinal uses, the most versatile period was the medieval (37), followed by the Renaissance (31), the classical (27), and the modern period (21). Considering the higher number of textual sources and use-records collected for the Renaissance period, the decrease of versatility in comparison to the medieval period appears robust. This seems to indicate a more consolidated use pattern, that might be conditioned by the reproduction of classic textual sources as well as by a less experimental approach and reduced popularity of mandrake in medicine. The introduction of the volatile anaesthetics with more reliable narcotic effects set the seal on using mandrake in surgery but opened the way for atropine being used as a prophylactic and antidote during surgical interventions.

Medical cannabis treatment for chronic pain: Outcomes and prediction of response.

BACKGROUND: Although studied in a few randomized controlled trials, the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicentre, questionnaire-based prospective cohort was aimed to assess the long-term effects of MC on chronic pain of various aetiologies and to identify predictors for MC treatment success. METHODS: Patients with chronic pain, licensed to use MC in Israel, reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. A general linear model was used to assess outcomes and identify predictors for treatment success (≥30% reduction in pain intensity). RESULTS: A total of 1,045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12-month follow-up. At 1 year, average pain intensity declined from baseline by 20% [-1.97 points (95%CI = -2.13 to -1.81; p < 0.001)]. All other parameters improved by 10%-30% (p < 0.001). A significant decrease of 42% [reduction of 27 mg; (95%CI = -34.89 to 18.56, p < 0.001)] from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non-serious. Presence of normal to long sleep duration, lower body mass index and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite. CONCLUSIONS: This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild-to-modest long-term improvement of the tested measures and identifying possible predictors for treatment success.

Cannabis and Pain Treatment-A Review of the Clinical Utility and a Practical Approach in Light of Uncertainty.

Over the past decade the phenomenon of cannabis as a legitimate form of treatment for pain has overwhelmed the medical community, especially in the field of pain. From a status of a schedule 1 substance having no currently accepted medical use and being considered to have high potential for abuse, its use has mushroomed to over 50,000 legal medical users per year in Israel alone. There appear to be many reasons behind this phenomenon-medical, sociological, and economical. Thus, what is cannabis? An abusive substance or a medication? Should it be incorporated into current biomedical practice, and how should it be administered? Finally, what is the evidence for the beneficial and detrimental effects of cannabis? This article reviews and discusses the current literature regarding the beneficial and the detrimental effects of medical cannabis in the treatment of pain. We further discuss the problems and challenges facing the medical community in this domain and offer a practical approach to deal with these challenges.

Medical cannabis and insomnia in older adults with chronic pain: a cross-sectional study.

OBJECTIVES: Medical cannabis (MC) is increasingly being used for treatment of chronic pain symptoms. Among patients there is also a growing preference for the use of MC to manage sleep problems. The aim of the current study was to examine the associations between use of whole plant cannabis and sleep problems among chronic pain patients. METHODS: A total of 128 individuals with chronic pain over the age of 50 years were recruited from the Rambam Institute for Pain Medicine in Haifa, Israel. Of them, 66 were MC users and 62 were non-users. Regression models tested the differences in sleep problems between the two groups. Furthermore, Pearson correlations between MC use measures (dose, length and frequency of use, number of strains used, tetrahydrocannabinol/cannabidiol levels) and sleep problems were assessed among MC users. RESULTS: After adjustment for age, sex, pain level and use of sleep and anti-depressant medications, MC use was associated with less problems with waking up at night compared with non-MC use. No group differences were found for problems with falling asleep or waking up early without managing to fall back asleep. Frequent MC use was associated with more problems waking up at night and falling asleep. CONCLUSIONS: MC use may have an overall positive effect on maintaining sleep throughout the night in chronic pain patients. At the same time, tolerance towards potential sleep-inducing properties of MC may occur with frequent use. More research based on randomised control trials and other longitudinal designs is warranted.

Cannabis treatment in hospitalized patients using the SYQE inhaler: Results of a pilot open-label study.

OBJECTIVE: The objectives were to evaluate the, usability, feasibility of use, satisfaction, and safety of the Syqe Inhaler Exo (Syqe Inhaler), a metered dose, Pharmacokinetics-validated, cannabis inhaler device in a cohort of hospitalized patients that were using medical cannabis under license as a part of their ongoing medical treatment. METHOD: Before and after inhaling from the Syqe Inhaler, participants were asked to fill a questionnaire regarding pain reduction on a visual analog scale from 0 to 10 and, if relevant, reduction in chemotherapy-induced nausea and vomiting and/or spasticity. A patient satisfaction questionnaire and a usability questionnaire were filled in following the last use. Prescribed treatment included 4 daily doses of 500 µg tetrahydrocannabinol each delivered from 16 mg cannabis flos per inhalation plus up to an additional four SOS (distress code for more doses of cannabis) doses. RESULT: Daily cannabis dose consumed during hospitalization with the Syqe Inhaler was 51 mg (20-96) versus 1,000 mg (660-3,300) consumed prehospitalization. Patients were easily trained and continued to use Syqe Inhaler for the duration of their hospitalization (5 [3-7] days). Pain intensity 30-60 minutes following inhalations was reported to be significantly lower than preinhalation 4 [1-5] versus 7 [2-9]). Participants ranked their satisfaction with Syqe Inhaler as 6 (5-7). Three participants reported mild cough, which resolved spontaneously. SIGNIFICANCE OF RESULTS: Cannabis inhalation by combustion is not feasible for hospitalized patients. The use of Syqe Inhaler during hospitalization yielded high levels of patients and staff satisfaction with no complications.

Rhetorical and regulatory boundary-work: The case of medical cannabis policy-making in Israel.

Recent studies have explored how professionals draw boundaries to reach workable solutions in conflictual and contested areas. Yet they neglected to explore the relationships and dynamics between how boundaries are demarcated in rhetoric and in policy. This article examines these relationships empirically through the case of medical cannabis (MC) policy-making in Israel. Drawing on interviews with key stakeholders in the MC policy field, formal policy documents, and observations of MC conferences, this article sheds light on the dynamics between rhetorical boundary-work and what we term regulatory boundary-work, namely setting rules and regulations to demarcate boundaries in actual practice. Results show how certain definitions of and rationales for a discursive separation between "medical" and "recreational" cannabis and between cannabis "medicalization" and "legalization" prevailed and were translated into formal policy, as well as how stakeholders' reactions to this boundary-work produced policy changes and the shifting of boundaries. Both rhetorical and regulatory boundary-works emerge as ongoing contested processes of negotiation, which are linked in a pattern of reciprocal influence. These processes are dominated by certain actors who have greater power to determine how and why specific boundaries should be drawn instead of others.

Twenty Thousand Needles Under the Sea. Trigger Point Dry Needling Aboard an Israeli Navy Submarine: A Case Report.

Nonspecific lower back pain affects a major part of the population at a certain point of their life. The intensity of pain can be debilitating and it causes a significant burden on society. Trigger point dry needling is a method of alleviating such pain by the introduction of needles into trigger points in muscles. A growing body of evidence supports its use in myofascial pain and specifically lower back pain. Submarine Medicine is a unique field due to the special characteristics and the environment of the submarine. It poses challenges that are not always seen by primary care physicians. Here, we present a case of a 40-yr-old senior submarine officer who complained of pain in his lower back and pelvis before departing on a mission. The pain persisted in spite of treatment with nonsteroidal anti-inflammatory drugs and he was then treated by the submarine's physician with trigger point dry needling. The officer showed rapid improvement following this treatment, both regarding pain and the range of motion.

Specialized Pain Clinics in Primary Care: Common Diagnoses, Referral Patterns and Clinical Outcomes - Novel Pain Management Model.

An estimated 19% of the adult population in western countries lives with chronic pain. Pain management lies mainly within the primary care and community setting. We evaluated the outcome of a new model of secondary care clinics, conducted by primary care physicians with specialized training in pain medicine. Data on referral patterns, prevalence of pain diagnosis, and medication consumption were recorded at five secondary pain management clinics in the community setting. In total, 997 patients with pain attended 2,652 visits (average 2.7 visits per patient) during 12 mo. Patients' age ranged from 18 to 92 yr (mean 59 ± 19). Mean pain intensity on the first visit, evaluated by the visual analogue scale was 7.7/10. Myofascial pain syndrome was the most common diagnosis (82%). Treatment included dry needling or trigger point injection (82%), manual myofascial release (23%), and pharmacotherapy (38%). Significant short-term improvement after treatment was reported by 75% of patients, and 72% reported long-term improvement. Four percent were referred to tertiary care pain clinics, 5% were referred to other specialists, and 5% to imaging. Secondary, community-based pain clinics, run by specially-trained primary physicians, demonstrated feasibility. The vast majority of patients referred to the clinics were treated using simple, inexpensive modalities, while sparing referrals to unnecessary consultation visits, imaging tests, and medications.

Medical students' attitudes towards participating in a palliative medicine course: A new specialty in Israel.

BACKGROUND: Palliative medicine is a growing field in Israel, and its training program is still in process. The current study aimed to evaluate students' attitudes regarding a course in palliative care established in a division of oncology. METHOD: Some 45 medical students in their 5th to 6th years participated in a one-week course on palliative care. At the end of each training week, students were asked to complete a questionnaire, evaluating their attitudes regarding different aspects of the program content, such as its importance and relevance to their training as physicians, as well as the contribution of specific parts of the program to their knowledge regarding palliative care. RESULTS: The overall satisfaction of the 45 students was high. The most contributory parts of the course were the multidisciplinary team and the complementary and alternative medicine. Participating in the staff meetings and accompanying physicians in their daily work were scored as the least contributory parts.Significance of resultsThis preliminary study demonstrated students' overall high satisfaction with the newly established palliative care course and their need for more practical skills. Future studies should investigate and evaluate educational programs in palliative care in order to establish suitable training for medical students.

The local and referred pain patterns of the longus colli muscle.

The longus colli muscle is a neck flexor believed to play an important role in pain originating in the neck region, including pain resulting from whiplash injuries. Despite the clinical importance attributed to it, the pain referral pattern of the longus colli has previously been described only in a small cohort of subjects. Here, we aim to delineate the pain referral pattern of the longus colli muscle. Thirty-five healthy volunteers underwent deep massage of the longus colli followed by dry needling of the muscle. The subjects depicted the distribution of the pain they experienced on a blank manikin. Their drawings were digitized and used to produce pain pattern histogram maps. The pain referral pattern during deep massage and needling of the longus colli was primarily local, with referral to the ipsilateral ear and lateral to the ipsilateral eye. Some subjects reported pain on the contralateral side of the neck.

Position Statement of the Israeli Society for Musculoskeletal Medicine on Intramuscular Stimulation for Myofascial Pain Syndrome-A Delphi Process.

OBJECTIVE: To develop consensus on a position paper on the use of intramuscular stimulation (IMS) for the treatment of myofascial pain syndrome (MPS) by physicians in Israel. METHODS: The Israeli Society of Musculoskeletal Medicine ran a modified Delphi process to gather opinions from a multidisciplinary expert panel. Eight experts in the treatment of MPS were chosen and asked to participate, and six participated. The position paper was iterated three times. RESULTS: After three iterations, general consensus was reached by all six experts. The general statement that was agreed on was: "IMS is one of the preferred treatments for myofascial pain syndrome. The treatment is evidence-based, effective, safe, and inexpensive. The position of the Israeli Society of Musculoskeletal Medicine is that the treatment should be taught and used by all primary care physicians and those physicians in other areas of medicine who deal with pain in their work." CONCLUSIONS: The position paper is a basis for clinical work and education programs for physicians interested in a better understanding and ability to treat patients with a musculoskeletal complaint or manifestation of disease.

Surface electromyographic recordings after passive and active motion along the posterior myofascial kinematic chain in healthy male subjects.

OBJECTIVE: To map the association of muscle activations along the superficial back line (SBL) using separate conditions of active range of motion with and without resistance and passive range of motion. METHOD: Using surface electromyography, electrodes were placed at specific points along the SBL. Twenty healthy adult males (aged 25.35 ± 1.24 years and body mass index 23.78 ± 2.12) underwent five test conditions. Conditions 1-3 involved passive movement, active movement and active movement against maximum isometric resistance (IR) of the right gastrocnemius and conditions 4 and 5 involved neck extension without and with isometric resistance from prone position. RESULTS: Passive and active motion without resistance found no significant (p > 0.05) correlations at any electrodes. Maximum IR yielded significant (p < 0.05) correlations with medium to very strong correlations at almost all electrodes. Neck extension without and with resistance showed significant medium to very strong correlations though the posterior superior iliac spine and right hamstring, respectively. CONCLUSION: Results demonstrated significant associations between the test condition muscle activations and muscle activations along the contiguous SBL. Thus, showing a need for a complete evaluation of the SBL in patients suffering from myofascial pain at all locations along it.

Trigger point needling: techniques and outcome.

In this review we provide the updates on last years' advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling.

Dry needling in the management of musculoskeletal pain.

Myofascial pain is a common syndrome seen by family practitioners worldwide. It can affect up to 10% of the adult population and can account for acute and chronic pain complaints. In this clinical narrative review we have attempted to introduce dry needling, a relatively new method for the management of musculoskeletal pain, to the general medical community. Different methods of dry needling, its effectiveness, and physiologic and adverse effects are discussed. Dry needling is a treatment modality that is minimally invasive, cheap, easy to learn with appropriate training, and carries a low risk. Its effectiveness has been confirmed in numerous studies and 2 comprehensive systematic reviews. The deep method of dry needling has been shown to be more effective than the superficial one for the treatment of pain associated with myofascial trigger points. However, over areas with potential risk of significant adverse events, such as lungs and large blood vessels, we suggest using the superficial technique, which has also been shown to be effective, albeit to a lesser extent. Additional studies are needed to evaluate the effectiveness of dry needling. There also is a great need for further investigation into the development of pain at myofascial trigger points.