Biphasic effects of cannabis and cannabinoid therapy on pain severity, anxiety and sleep disturbance: A scoping review.

INTRODUCTION: Cannabinoids are being used by patients to help with chronic pain management and to address the two primary chronic pain comorbidities of anxiety and sleep disturbance. It is necessary to understand the biphasic effects of cannabinoids to improve treatment of this symptom triad. METHODS: A scoping review was conducted to identify whether biphasic effects of cannabinoids on pain severity, anxiolysis, and sleep disturbance have been reported. The search included Embase, Biosis and Medline databases of clinical literature published between 1970-2021. The inclusion criteria were: 1) adults over 18 years of age; 2) data or discussion of dose effects associated with u-shaped or linear dose responses and 3) measurements of pain and/or anxiety and/or sleep disturbance. Data were extracted by two independent reviewers (third reviewer used as a tiebreaker) and subjected to a thematic analysis. RESULTS: After database search and study eligibility assessment, 44 publications met the final criteria for review. 18 publications that specifically provided information on dose response were included in the final synthesis: 9 related to pain outcomes, 7 measuring anxiety, and 2 reporting sleep effects. CONCLUSIONS: This scoping review reports on biphasic effects of cannabinoids related to pain, sleep, and anxiety. Dose response relationships are present, but we found gaps in the current literature for biphasic effects of cannabinoids in humans. There is a lack of prospective research in humans exploring this specific relationship.

A Hybrid Musculoskeletal Ultrasound Curriculum for Physical Medicine and Rehabilitation Residents-a Multi-center Pilot Program.

Purpose of Review: The increased use of musculoskeletal ultrasound (MSKUS) in clinical practice warrants achieving competency earlier in physiatrists' careers. Physical Medicine and Rehabilitation (PM&R) residency programs have started incorporating formal MSKUS training in their curricula; however, significant heterogeneity remains in MSKUS education. Recent Findings: Numerous barriers contribute to the lack of consensus for MSKUS training during residency, but the COVID-19 pandemic severely disrupted in-person learning. As an adjunct or alternative to in-person learning, teleguided technology is being utilized. Summary: This curriculum demonstrates the role of a hybrid MSKUS training with interinstitutional collaboration. Twenty PM&R learners, from two institutions, were divided into a fundamental or advanced track. Virtual didactic sessions alternated weekly with hands-on ultrasonographic scanning sessions. Following a 12-month longitudinal curriculum, an end-of-year practical examination was used for competency assessment, in addition to a survey assessing resident perceptions and feedback. To our knowledge, this is the first collaborative and hybrid MSKUS curriculum for PM&R learners that can be easily reproduced at most training institutions and circumvent some of the barriers amplified by the COVID-19 pandemic. Supplementary Information: The online version contains supplementary material available at 10.1007/s40141-023-00380-z.

Genicular Nerve Anatomy and Its Implication for New Procedural Approaches for Knee Joint Denervation: A Cadaveric Study.

OBJECTIVE: To verify the articular branch contributions in the human knee, delineate their anatomical variance, and outline the limitations of currently applied procedure protocols for denervation of the knee joint. DESIGN: A detailed anatomical dissection. SETTING: Cadavers in residence at the Albert Einstein College of Medicine. SUBJECTS: In total, 24 lower extremity specimens from 14 embalmed cadavers. METHODS: Human cadaveric dissections were performed on 24 lower extremities from 14 embalmed cadavers. RESULTS: This cadaveric study has demonstrated that the anterior knee receives sensory innervations from SMGN, SLGN, LRN, NVI, NVL, RFN, and IMGN. The courses of SMGN, SLGN, RFN, and IMGN are similar to recent anatomical studies. However, discrepancies exist in their relative anatomy to bony and radiographic landmarks. CONCLUSIONS: Genicular denervation using classical anatomical landmarks may not be sufficient to treat the anterior knee joint pain. Our findings illustrate more accurate anatomic landmarks for the three-target paradigm and support additional targets for more complete genicular denervation. This cadaveric study provides robust anatomical findings that can provide a foundation for new anatomical landmarks and targets to improve genicular denervation outcomes.

Musculoskeletal Ultrasound as a Motivator for Selecting a Physical Medicine and Rehabilitation Residency Program in the United States: A Multicenter Survey Study.

ABSTRACT: This study aimed to determine the influence of musculoskeletal ultrasound (MSKUS) curriculum on applicants during the residency-selection process. A survey of 666 applicants for the Johns Hopkins University, Mayo Clinic, and Harvard/Spaulding Rehabilitation Physical Medicine and Rehabilitation programs was conducted in June 2020. A total of 180 respondents scored the influence of a MSKUS curriculum on their decision making for residency selection. In addition, applicants were asked to rank specific areas of physical medicine and rehabilitation that influenced their decision making. Participants most commonly included MSKUS in their top three areas of interest when constructing their rank order list. When asked whether MSKUS presence within a program had an effect during the interview-selection process, 71% responded with "very important" or "absolutely essential" (P < 0.001). For 74% of applicants, exposure to MSKUS in residency was an important factor when creating their rank order list (P < 0.001). More than 92% of applicants stated that they are "likely" or "very likely" to use MSKUS in their future practice and 83% would recommend a program with MSKUS to future candidates (P < 0.001). Based on these results, a large percentage of physical medicine and rehabilitation applicants intend on using MSKUS in their future practice. Therefore, MSKUS may be an important factor for residency selection.

Dexamethasone Effectively Reduces the Incidence of Post-neurotomy Neuropathic Pain: A Randomized Controlled Pilot Study.

BACKGROUND: Radiofrequency neurotomy (RFN) of facet or sacroiliac joints is widely used for the treatment of chronic axial pain and can provide long-term pain relief in well-selected patients. The most common side effect is transient neuropathic pain at the paravertebral level of interest. Pain physicians commonly administer corticosteroid post-neurotomy to reduce the risk of post-neurotomy neuropathic pain, yet it remains unclear if this provides a true reduction in incidence. OBJECTIVES: To determine the efficacy of corticosteroid administration post-lesion in preventing the development of post-neurotomy neuropathic pain after cervical, thoracic, lumbar, and sacroiliac joint radiofrequency denervation. STUDY DESIGN: Randomized, placebo-controlled, double-blind prospective study. SETTING: Ambulatory Surgical Center within a Tertiary Hospital System. METHODS: This trial is registered on ClinicalTrials.gov (NCT03247413). Permission to conduct human research was obtained from the Institutional Review Board. Eligible patients included those with cervical, thoracic, or lumbar facet or sacroiliac joint pain who had positive concordant medial branch blocks (thus scheduled for bilateral RFN), at least 18 years of age, and English-speaking. Patients received dexamethasone vs saline (control) at each lesion site, serving as their own control (with laterality). Follow-ups were completed at 4- and 8-weeks post-intervention to evaluate the incidence of post-procedure pain (questionnaire) and function using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). RESULTS: At the time of data analysis, 35/63 patients completed the study protocol. There was a statistically significant reduction in the incidence of post-neurotomy pain in the steroid group vs the control group (20/35 control group vs 3/35 steroid group, P < 0.001). ODI/NDI scores changed differently over time depending on the spinal level of neurotomy, showing statistically significant improvement in ODI/NDI in the cervical subgroup and lumbar subgroup at 4-week (P = 0.05) and 8-week time points (P < 0.01), respectively. There was no improvement of ODI scores in the sacral subgroup. The incidence of post-neurotomy neuropathic pain was not significantly different among patients with different spinal levels of neurotomy. Patients who developed post-neurotomy neuropathic pain did not differ in ODI/NDI scores at any time point. LIMITATIONS: This study has several limitations, most notably the number of patients lost to follow-up, the use of a single corticosteroid, and the use of laterality for incidence reporting. Additionally, all procedures were performed by a single interventionalist using one neurotomy system. CONCLUSIONS: A statistically significant reduction in post-neurotomy pain was observed in the steroid group. This protocol can be feasibly conducted in an effective and resource-efficient manner. Additional research is needed to increase the power of the study.