A Review of the Evidence and Current Applications of Portable Translingual Neurostimulation Technology.

OBJECTIVES: Translingual neurostimulation (TLNS) with adjunct physical rehabilitation is used to treat balance and gait deficits in several chronic neurological conditions. The purpose of this review is to summarize and appraise the evidence currently available on the portable TLNS device and to assess its potential clinical application. MATERIALS AND METHODS: In this narrative review, MEDLINE, EMBASE, Web of Science, and Google Scholar were searched for primary research investigating the use of portable TLNS devices on any neurologic condition. Data were extracted, reviewed, and appraised with respect to study design, conduct, and reporting. RESULTS: Five randomized controlled trials (RCTs), three quasi-experimental trials, and seven case reports/series were found. Most studies demonstrated improvements in balance and gait deficits secondary to traumatic brain injury and multiple sclerosis, but evidence is also present to a lesser degree for stroke and balance disorder patients. In these studies, the feasibility and safety of TLNS have been convincingly demonstrated. Functional magnetic resonance studies have also suggested a plausible neuroplastic therapeutic mechanism. However, the efficacy of TLNS remains unclear due to bias and confounding within studies, and heterogeneity of results between studies. CONCLUSIONS: TLNS is a promising treatment modality for various chronic neurological conditions that are often refractory to conventional therapy. However, TLNS technology remains largely investigational as high-quality RCTs are still required to elucidate efficacy, optimal dosages, necessary treatment durations, and treatment durability. Further research to develop an appropriate control group is needed for scientifically valid comparisons of TLNS.

Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation.

A commonly disputed medicolegal issue is the documentation of the location, degree, and anatomical source of an injured plaintiff's ongoing pain, particularly when the painful region is in or near the spine, and when the symptoms have arisen as result of a relatively low speed traffic crash. The purpose of our paper is to provide health and legal practitioners with strategies to identify the source of cervical pain and to aid triers of fact (decision makers) in reaching better informed conclusions. We review the medical evidence for the applications and reliability of cervical medial branch nerve blocks as an indication of painful spinal facets. We also present legal precedents for the legal admissibility of the results of such diagnostic testing as evidence of chronic spine pain after a traffic crash. Part of the reason for the dispute is the subjective nature of pain, and the fact that medical documentation of pain complaints relies primarily on the history given by the patient. A condition that can be documented objectively is chronic cervical spine facet joint pain, as demonstrated by medial branch block (injection). The diagnostic accuracy of medial branch blocks has been extensively described in the scientific medical literature, and evidence of facet blocks to objectively document chronic post-traumatic neck pain has been accepted as scientifically reliable in courts and tribunals in the USA, Canada and the United Kingdom. We conclude that there is convincing scientific medical evidence that the results of cervical facet blocks provide reliable objective evidence of chronic post-traumatic spine pain, suitable for presentation to an adjudicative decision maker.

Medical Cannabis for the Management of Pain and Quality of Life in Chronic Pain Patients: A Prospective Observational Study.

OBJECTIVE: To evaluate the short-term and long-term effects of plant-based medical cannabis in a chronic pain population over the course of one year. DESIGN: A longitudinal, prospective, 12-month observational study. SETTING: Patients were recruited and treated at a clinic specializing in medical cannabis care from October 2015 to March 2019. SUBJECTS: A total of 751 chronic pain patients initiating medical cannabis treatment. METHODS: Study participants completed the Brief Pain Inventory and the 12-item Short Form Survey (SF-12), as well as surveys on opioid medication use and adverse events, at baseline and once a month for 12 months. RESULTS: Medical cannabis treatment was associated with improvements in pain severity and interference (P < 0.001) observed at one month and maintained over the 12-month observation period. Significant improvements were also observed in the SF-12 physical and mental health domains (P < 0.002) starting at three months. Significant decreases in headaches, fatigue, anxiety, and nausea were observed after initiation of treatment (P ≤ 0.002). In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses (P < 0.0001), while correlates of pain were significantly improved by the end of the study observation period. CONCLUSIONS: Taken together, the findings of this study add to the cumulative evidence in support of plant-based medical cannabis as a safe and effective treatment option and potential opioid medication substitute or augmentation therapy for the management of symptoms and quality of life in chronic pain patients.

Benefits, Safety, and Adjunct Modality Prevalences of Long-Term Botulinum Toxin Injections for Cervical Dystonia and Myofascial Neck Pain: A Retrospective Cohort Study.

INTRODUCTION: There is a paucity of long-term treatment benefit and safety data of botulinum toxin A (BTX-A) for cervical dystonia (CD) and myofascial neck pain syndrome (MPS). Additionally, the prevalence of adjunct modality uses during this period is unknown despite evolving practices. OBJECTIVE: To assess and compare treatment benefit, safety, and adjunct modality prevalences of long-term BTX-A injections between CD and MPS patients. DESIGN: Retrospective cohort study. SETTING: Private practice tertiary care clinics in Toronto. PATIENTS: Convenience sample of 37 (52.9%) CD and 33 (47.1%) MPS patients treated for a mean±SD duration of 7.2±4.3 and 8.3±4.7 years, respectively. INTERVENTIONS: BTX-A injections administered at least once yearly, for a duration longer than 1 year. MAIN OUTCOME MEASURES: Toronto Western Spasmodic Torticollis Rating Scales (TWSTRS) for disability and pain, Patient Global Impression of Change (PGIC) score, time to peak effect, duration of total response, adverse effects, and prevalence of adjunct modalities. RESULTS: CD patients experienced improvements in TWSTRS disability (17.57±6.79 to 9.81±4.35, p<0.001) and pain (14.61±3.08 to 9.05±3.49, p<0.001) scores as well as PGIC score (52.00%±23.60% to 64.80%±23.60%, p=0.007). MPS patients experienced improvements in TWSTRS disability (15.86±7.70 to 10.07±7.01, p=0.01) and pain (15.25±4.09 to 10.85±4.49, p=0.01) scores. In both cohorts, there were no changes in time to peak effect and duration of total response. Adverse effects were minimal and self-limiting. Prevalences of adjunct modalities used by CD versus MPS patients were 28.13% versus 50.00% for anesthetic procedures, 23.08% versus 15.38% for image-guidance, 65.71% versus 56.25% for pectoralis minor injections, and 47.06% versus 53.13% for cannabis-use. CONCLUSION: There were demonstrated and comparable treatment benefit, safety, and adjunct modality prevalences. Our study is the first to demonstrate that long-term BTX-A injections for MPS, although commonly used off-label, can be effective and safe.

Beyond the muscular effects - onabotulinumtoxinA injections for pain control in chronic knee osteoarthritis: a case report.

We present a long-standing case of an 88-year-old woman with multiple comorbidities receiving intra-articular Botox® (onabotulinumtoxinA) injections for bilateral chronic knee osteoarthritis. She reported improved pain control and function supported by validated outcome measures.

Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction.

BACKGROUND: Two-thirds of adults worldwide will experience low back pain at some point in their life. In the following case series, we present four patients with sacroiliac (SI) joint instability and severe chronic low back pain, which was refractory to other treatment modalities. OBJECTIVE: We investigated the efficacy of platelet-rich plasma (PRP) injections, a novel orthobiologic therapy, for reducing SI joint pain, improving quality of life, and maintaining a clinical effect. METHODS: Short-form McGill Pain Questionnaire (SFM), Numeric Rating Scale (NRS), and Oswestry Low Back Pain and Disability Index were used for evaluation of treatment at pretreatment, 12-months and 48-months after treatment. RESULTS: At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life. The clinical benefits of PRP were still significant at 4-years post-treatment. CONCLUSIONS: Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.

Medical cannabis - the Canadian perspective.

Cannabis has been widely used as a medicinal agent in Eastern medicine with earliest evidence in ancient Chinese practice dating back to 2700 BC. Over time, the use of medical cannabis has been increasingly adopted by Western medicine and is thus a rapidly emerging field that all pain physicians need to be aware of. Several randomized controlled trials have shown a significant and dose-dependent relationship between neuropathic pain relief and tetrahydrocannabinol - the principal psychoactive component of cannabis. Despite this, barriers exist to use from both the patient perspective (cost, addiction, social stigma, lack of understanding regarding safe administration) and the physician perspective (credibility, criminality, clinical evidence, patient addiction, and policy from the governing medical colleges). This review addresses these barriers and draws attention to key concerns in the Canadian medical system, providing updated treatment approaches to help clinicians work with their patients in achieving adequate pain control, reduced narcotic medication use, and enhanced quality of life. This review also includes case studies demonstrating the use of medical marijuana by patients with neuropathic low-back pain, neuropathic pain in fibromyalgia, and neuropathic pain in multiple sclerosis. While significant preclinical data have demonstrated the potential therapeutic benefits of cannabis for treating pain in osteoarthritis, rheumatoid arthritis, fibromyalgia, and cancer, further studies are needed with randomized controlled trials and larger study populations to identify the specific strains and concentrations that will work best with selected cohorts.

Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia: a summary report.

OBJECTIVE: To summarize the development of evidence-based guidelines for the clinical care of persons with fibromyalgia (FM), taking into account advances in understanding of the pathogenesis of FM, new diagnostic criteria, and new treatment options. METHODS: Recommendations for diagnosis, treatment, and patient followup were drafted according to the classification system of the Oxford Centre for Evidence-Based Medicine, and following review were endorsed by the Canadian Rheumatology Association and the Canadian Pain Society. RESULTS: FM is a polysymptomatic syndrome presenting a spectrum of severity, with a pivotal symptom of body pain. FM is a positive clinical diagnosis, not a diagnosis of exclusion, and not requiring specialist confirmation. There are no confirmatory laboratory tests, although some investigation may be indicated to exclude other conditions. Ideal care is in the primary care setting, incorporating nonpharmacologic and pharmacologic strategies in a multimodal approach with active patient participation. The treatment objective should be reduction of symptoms, but also improved function using a patient-tailored treatment approach that is symptom-based. Self-management strategies combining good lifestyle habits and fostering a strong locus of control are imperative. Medications afford only modest relief, with doses often lower than suggested, and drug combinations used according to clinical judgment. There is a need for continued reassessment of the risk-benefit ratio for any drug treatment. Outcome should be aimed toward functioning within a normal life pattern and any culture of disablement should be discouraged. CONCLUSION: These guidelines should provide the health community with reassurance for the global care of patients with FM with the aim of improving patient outcome by reducing symptoms and maintaining function.

2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary.

BACKGROUND: Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population. OBJECTIVES: To present the evidence-based guidelines for the diagnosis, management and patient trajectory of individuals with FM. METHODS: A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice. RESULTS: The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged. CONCLUSIONS: The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.

A case of pseudo-angina pectoris from a pectoralis minor trigger point caused by cross-country skiing.

OBJECTIVE: The aim of this article is to illustrate the pectoralis minor muscle as a possible pain source in patients with anterior chest pain, especially those who are known to be beginner cross-country skiers. CLINICAL FEATURES: A 58-year-old man presented with anterior chest pain and normal cardiac examination findings. Upon history taking and physical examination, the chest pain was determined to be caused by active trigger points in the pectoralis minor muscle. INTERVENTION AND OUTCOME: The patient was treated with Graston Technique and cross-country skiing technique advice. The subject's symptoms improved significantly after 2 treatments and completely resolved after 4 treatments. CONCLUSION: This case demonstrates the importance of differential diagnosis and mechanism of injury in regard to chest pain and that chiropractic management can be successful when addressing patients with chest wall pain of musculoskeletal origin.

Omega-3 fatty acids for neuropathic pain: case series.

OBJECTIVE: The aim of this case series study was to investigate and report on patients with neuropathic pain who responded to treatment with omega-3 fatty acids. METHODS: Methods: Five patients with different underlying diagnoses including cervical radiculopathy, thoracic outlet syndrome, fibromyalgia, carpal tunnel syndrome, burn injury were treated with high oral doses of omega 3 fish oil (varying from 2400-7200 mg/day of EPA-DHA). Outcome measures were obtained pretreatment and posttreatment. These included validated surveys (short-form McGill Pain questionnaire, DN4 neuropathic pain scale, Pain Detect Questionnaire), objective clinical tools (Jamar grip strength, Lafayette dynamometry, tender point algometry) and EMG Nerve Conduction studies. RESULTS: These patients had clinically significant pain reduction, improved function as documented with both subjective and objective outcome measures up to as much as 19 months after treatment initiation. No serious adverse effects were reported. CONCLUSIONS: This first-ever reported case series suggests that omega-3 fatty acids may be of benefit in the management of patients with neuropathic pain. Further investigations with randomized controlled trials in a more specific neuropathic pain population would be warranted.

Chiropractic management of fibromyalgia syndrome: a systematic review of the literature.

OBJECTIVE: Fibromyalgia syndrome (FMS) is one of the most commonly diagnosed nonarticular soft tissue conditions in all fields of musculoskeletal medicine, including chiropractic. The purpose of this study was to perform a comprehensive review of the literature for the most commonly used treatment procedures in chiropractic for FMS and to provide evidence ratings for these procedures. The emphasis of this literature review was on conservative and nonpharmaceutical therapies. METHODS: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. Online comprehensive literature searches were performed of the following databases: Cochrane Database of Systematic Reviews; National Guidelines Clearinghouse; Cochrane Central Register of Controlled Trials; Manual, Alternative, and Natural Therapy Index System; Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature; Allied and Complementary Medicine; and PubMed up to June 2006. RESULTS: Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, and 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic randomized clinical trials that were not already included in one or more of the systematic reviews/guidelines. The review of the Manual, Alternative, and Natural Therapy Index System and Index to Chiropractic Literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following recommendations regarding nonpharmaceutical treatments of FMS. Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification. CONCLUSIONS: Several nonpharmacologic treatments and manual-type therapies have acceptable evidentiary support in the treatment of FMS.

Effect of ceramic-impregnated "thermoflow" gloves on patients with Raynaud's syndrome: randomized, placebo-controlled study.

OBJECTIVE: To determine the efficacy of ceramic impregnated gloves in the treatment of Raynaud's syndrome. DESIGN: Double-blind, placebo-controlled study. SETTING: Teaching hospital outpatient clinic. PARTICIPANTS: Ninety-three patients meeting the "Pal" criteria for Raynaud's syndrome. INTERVENTIONS: Treatment period of three months with use of ceramic-impregnated gloves. MAIN OUTCOME MEASURES: Primary end points: Pain visual analogue scale ratings and diary; Disabilities of the Arm, Shoulder, Hand questionnaire; Jamar grip strength; Purdue board test of hand dexterity. Secondary end points: Infrared skin temperature measurements; seven-point Likert scale rating of treatment. RESULTS: In 60 participants with complete data, improvements were noted in the visual analogue scale rating (p=0.001), DASH score (p=0.001), Jamar grip strength (p=0.002), infrared skin fingertip temperature (p=0.003), Purdue hand dexterity test (p=0.0001) and the Likert scale (p=0.001) with ceramic gloves over the placebo cotton gloves. CONCLUSION: The ceramic-impregnated "thermoflow" gloves have a clinically important effect in Raynaud's syndrome.