Implementation of Electrical Auricular Acupuncture and Low Frequency Modulated Electric Current Therapy in Pain Management of Patients with Knee Osteoarthritis: A Randomized Pilot Trial.

BACKGROUND: Knee osteoarthritis is a major cause of knee pain. Conservative therapy resources are limited due to adverse effects. Therefore, alternative non-invasive therapy approaches to reduce pain medications are gaining importance. The current study analyses if electrical auricular acupuncture (EAA) or low frequency modulated electric current therapy (LFMECT) could support analgesic treatment. METHODS: In a randomized pilot trial patients with painful knee OA were treated with EAA (group 1) or LFMECT (group 2) additional to standard pharmacological analgesic treatment. In total 19 female and 10 male patients with a mean age of 59.1 years (standard deviation ± 13.6) and a mean BMI of 28.9 kg/m2 (± 5.2) were included. Patients were randomly assigned to one of the groups stratified for age, gender and BMI. Before starting of the active study period and collecting of the initial data on day 1, all patients received a pharmacological analgesic baseline therapy for one week. At the next study stage patients started their randomly assigned treatment protocol for 42 days and final follow-up was set on day 70. Patients recorded their pain intensity (numerical rating scale; NRS) using a standardized patient diary. The pain free walking time in min was recorded and range of motion was assessed. RESULTS: Rescue medication intake was comparable between both groups on day 42 (p = 0.55) and day 70 (p = 0.35). After the active study period (day 42) pain scores decreased significantly in both groups (group 1 p = 0.02; group 2 p = 0.0006). At follow up median pain scores further decreased in group 1 (p = 0.0002) and remained at a low level in group 2 (p = 0.001). Level of pain decreased in about 50% in both groups and was comparable during the study period. Total mean range of motion (ROM) increased in both groups (group 1 p = 0.0003; group 2 p = 0.02). Group 1 had more improvement of mean total ROM compared to group 2 (p = 0.034). Pain-free walking time increased in both groups and was comparable between both groups (p = 0.31). Any adverse effects due to EAA or LFMECT were not observed. CONCLUSIONS: Data of the current study indicates that implementation of EAA or LFMECT seems to be beneficial to reduce knee pain and improve knee function in patients with knee osteoarthritis.

The effects of auricular electroacupuncture on obesity in female patients--a prospective randomized placebo-controlled pilot study.

BACKGROUND: Obesity is a chronic condition related to serious morbidity and mortality of increasing incidence and prevalence. Several studies show a significantly higher weight loss with acupuncture treatment. This is the first prospective, randomized, double-blinded study, testing the effects of auricular electroacupuncture on weight loss in obese female patients. METHODS: 56 female obese patients (age>18, Body Mass Index, BMI>25) were randomized to receive either auricular acupuncture with electrical stimulation with a P-Stim® device (verum group, n=28) or placebo treatment with a P-Stim® dummy (n=28) for four days. Three auricular acupuncture points were chosen (hunger 18, stomach 87 and colon 91). The treatment was performed once a week for a period of six weeks. A follow-up visit was performed after 4 weeks. At each visit body weight, BMI (Body Mass Index) and body fat were measured. RESULTS: Relative reduction of body weight was significantly greater in the verum group (-3.73%; CI=-4.70 to -2.76) than in the placebo group (-0.70%; CI=-1.57 to +0.16; p<0.001) In addition we also observed a significant reduction of BMI (p<0.001) in the verum group (-3.62%; CI=-4.39 to -2.84) compared to placebo (-0.82%; CI=-1.55 to -0.10; p<0.001). No patient reported side effects related to acupuncture. CONCLUSION: In conclusion electrical auricular acupuncture could be a safe, additive, non-pharmacological treatment in obese patients.

Peripheral nerve field stimulation (PNFS) in chronic low back pain: a prospective multicenter study.

OBJECTIVES: The goal of this study was to evaluate the long-term efficacy and safety of peripheral nerve field stimulation (PNFS) for chronic low back pain (cLBP). MATERIALS AND METHODS: In this prospective, multicenter observational study, 118 patients were admitted to 11 centers throughout Austria and Switzerland. After a screening visit, all patients underwent a trial stimulation period of at least seven days before implantation of the permanent system. Leads were placed in the subcutaneous tissues of the lower back directly in the region of greatest pain. One hundred five patients were implanted with a permanent stimulating system. Patients' evaluation of pain and functional levels were completed before implantation and one, three, and six months after implantation. Adverse events, medication usage, and coverage of the painful area and predictive value of transcutaneous electrical nerve stimulation (TENS) were monitored. RESULTS: All pain and quality-of-life measures showed statistically significant improvement during the treatment period. These included the average pain visual analog scale, the Oswestry Disability Questionnaire, the Becks Depression Inventory, and the Short Form-12 item Health survey. Additionally, medication usage with opioids, nonsteroidal anti-inflammatory drugs, and anti-convulsants showed a highly significant reduction. Complications requiring surgical intervention were reported in 9.6% of the patients. The degree of coverage of painful areas seems to be an important criterion for efficacy of PNFS, whereas TENS is presumably no predictor. CONCLUSIONS: This prospective, multicenter study confirms that PNFS is an effective therapy for the management of cLBP. Significant improvements in many aspects of the pain condition were measured, and complications were minimal.

Surgical treatment of complex regional pain syndrome type II with regional subcutaneous venous sympathectomy.

BACKGROUND: The effectiveness of a new surgical technique for the treatment of severe chronic pain stages was evaluated. For the last 140 years, the treatment of complex regional pain syndrome type II (CRPS II) has been an unsolved problem. Therapeutic approaches have included conventional pain medication, physical therapy, sympathetic blocks, transcutaneous or spinal cord stimulation, injections or infusion therapies, and sympathectomy. When used alone or in combination, these therapies often yield unfavorable results. The majority of physicians who treat patients with CRPS are convinced that a surgical treatment of the affected extremity only exacerbates the symptoms, especially its hallmark excruciating pain. METHODS: Sixteen patients with a CRPS type II of the upper or lower limb were included in the study after ineffective pain therapy for more than 6 months. The most proximal region of pain associated with CRPS was localized, and 2% lidocaine was injected into that area. Once the sympathetic, deep, burning pain had been blocked, the subcutaneous veins in the previously determined area were surgically removed. A visual analog scale, the Nottingham Health Profile, and physical examinations were used to evaluate the outcome of the operation. RESULTS: Twelve (75%) surgically treated patients showed significant improvement in limb function, the visual analog scale, and the Nottingham Health Profile. CONCLUSIONS: These data and recent findings in animal models conclude that CRPS type II is maintained by a coupling of newly sprouted sympathetic and sensible fibers. These fibers can be resected with a regional subcutaneous venous sympathectomy. LEVEL OF EVIDENCE: Therapeutic study, level III.

Subcutaneous target stimulation (STS) in chronic noncancer pain: a nationwide retrospective study.

Stimulation of primary afferent neurons offers a new approach for the control of localized chronic pain. We describe the results with a new neurostimulation technique, subcutaneous target stimulation (STS), for the treatment of chronic focal noncancer pain. STS applies permanent electrical stimulation directly at the painful area via a percutaneous-placed subcutaneous lead. We reported the clinical outcomes of 111 patients with focal chronic, noncancer pain treated with STS in this first nationwide, multicenter retrospective analysis. The indications for STS were low back pain (n = 29) and failed back surgery syndrome (back pain with leg pain) (n = 37), cervical neck pain (n = 15), and postherpetic neuralgia (n = 12). Pain intensity was measured on a numerical rating scale (NRS) before and after implantation. Data on analgesic medication, stimulation systems, position, and type of leads and complications were obtained from the patients' records. After implantation, the mean pain intensity improved by more than 50% (mean NRS reduction from 8.2 to 4.0) in the entire patient group (P = 0.0009). This was accompanied by a sustained reduction in demand for analgesics. In all the patients, the STS leads were positioned directly at the site of maximum pain. Lead dislocation occurred in 14 patients (13%), infections in 7 (6%), and in 6 cases (5%), lead fractures were observed. The retrospective data analysis revealed that STS effectively provided pain relief in patients suffering from refractory focal chronic noncancer pain and that STS is an alternative treatment option. Prospective controlled studies are required to confirm these retrospective findings. This article presents a new minimally invasive technique for therapy-resistant focal pain.

Perioperative auricular electroacupuncture has no effect on pain and analgesic consumption after third molar tooth extraction.

BACKGROUND: Auricular acupuncture (AA) has been shown to alleviate acute and chronic pain. We investigated the effects of auricular electroacupuncture (AE) on pain and analgesic drug consumption in the first 48 h after unilateral mandibular third molar tooth extraction under local anesthesia in a prospective, randomized, double-blind, placebo-controlled study in 149 patients. METHODS: Patients received either AA with electrical stimulation (AE, n = 76) or without (AA, n = 37) electrical stimulation at an alternating frequency of 2/100 Hz or a sham AE with metal plates instead of needles and no electrical stimulation, no-needle (NN, n = 36) at the AA points 1 (tooth), 55 (Shen men) and 84 (mouth) during the entire study period. Regularly rated pain intensity (five-point verbal rating scale), consumption of acetaminophen 500 mg tablets and additional rescue medication with mefenamic acid 500 mg were assessed. RESULTS: The median fraction of time when pain was rated as moderate or worse (upper and lower quartile): AE: 33% (12%, 64%), AA: 22% (6%, 56%), NN: 30% (7%, 53%) did not differ significantly among the treatment groups. There were no significant differences in mean number of acetaminophen 500 mg tablets (range): AE: 5.2 (0-12), AA: 4.6 (0-11), NN: 5.4 (0-10) or percentage of patients requiring additional mefenamic acid: AE: 19%, AA: 18%, NN: 19%. CONCLUSION: We conclude that neither AE nor AA alone reduce either pain intensity or analgesic consumption in a molar tooth extraction model of acute pain.

P-Stim auricular electroacupuncture stimulation device for pain relief.

Acupuncture is now accepted as a complementary analgesic treatment. Auricular acupuncture is a distinct form of acupuncture. Electrical stimulation of acupoints (electroacupuncture) increases the effects of acupuncture. Recently, an auricular electroacupuncture device, the P-Stim, has become available. Clinical studies in outpatients have investigated the P-Stim in chronic musculoskeletal pain and its use for minor surgery. In chronic cervical or low back pain, auricular electroacupuncture was more effective than conventional auricular acupuncture. The results in acute pain were controversial. Auricular electroacupuncture reduced pain and remifentanil consumption during oocyte aspiration when compared with conventional auricular acupuncture or a sham treatment. However, after third molar tooth extraction, auricular electroacupuncture and auricular acupuncture failed to reduce either postoperative pain or analgesic consumption. Further large-scale studies are required to evaluate the analgesic efficacy of auricular electroacupuncture.

Auricular electro-acupuncture as an additional perioperative analgesic method during oocyte aspiration in IVF treatment.

BACKGROUND: The aim of this study was to compare the pain-relieving effect and the subjective well-being between auricular electro-acupuncture (EA) analgesia, auricular acupuncture (A) and conventional analgesia with remifentanil (CO). METHODS: A total of 94 women undergoing IVF were randomized to auricular acupuncture with (EA, n = 32) or without (A, n = 32) continuous 1 Hz auricular stimulation (using a battery-powered miniaturized stimulator, P-Stim) or with adhesive tapes instead of needles and no electrical stimulation (control group, CO, n = 30) at the auricular acupuncture points 29, 55 and 57. All patients received patient-controlled analgesia (PCA) with remifentanil. Pain intensity and psychological well-being were assessed by means of visual analogue scales (VAS); tiredness, nausea and vomiting and analgesic drug consumption were documented. RESULTS: Pain relief and subjective well-being were significantly greater in group EA during and after the procedure as compared with groups A and CO (P < 0.001). The patients were significantly more tired in group CO than in groups A and EA (P < 0.001). Consumption of the opioid remifentanil was significantly lower in group EA, comparable nausea (P < 0.001). CONCLUSION: Auricular EA significantly reduces pain intensity and analgesic consumption of the opioid remifentanil during oocyte aspiration in IVF treatment.

S(+)-ketamine for long-term sedation in a child with retinoblastoma undergoing interstitial brachytherapy.

We report the case of a 14-month-old child undergoing hourly pulse dose radiation therapy (interstitial brachytherapy) for 72 h in whom we employed S(+)-ketamine for sedation during spontaneous breathing.

Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study.

BACKGROUND: The aim of this study was to compare the efficacy and side effects of gabapentin, amitriptyline, and their combination in women with chronic pelvic pain. METHODS: In this open-label, prospective, randomized trial, 56 women with chronic pelvic pain were investigated with a two-year follow-up at the Vienna Medical University Hospital. If pain intensity assessed by a visual analog scale (VAS) was 5 or more (0, no pain; 10, maximal pain), despite analgesic therapy using the nonopioid drug metamizol together with weak opioids, patients were randomized to receive gabapentin (n = 20), amitriptyline (n = 20), or a combination of both drugs (n = 16). Doses of gabapentin and amitriptyline were increased to maximum daily doses of 3600 mg and 150 mg, respectively, until sufficient pain relief or the occurrence of side effects. VAS and side effects were evaluated before treatment and at 1, 3, 6, 12 and 24 months afterwards. RESULTS: All patients experienced significant pain relief during the observation period. However, after 6, 12 and 24 months, pain relief was significantly better in patients receiving gabapentin either alone or in combination with amitriptyline than in patients receiving monotherapy with amitriptyline (gabapentin: 0 months, 7.7 +/- 1.5; 6 months, 1.6 +/- 0.9; 12 months, 1.5 +/- 0.9; 24 months, 1.9 +/- 0.9; amitriptyline: 0 months, 7.3 +/- 1.5; 6 months, 2.2 +/- 1.6; 12 months, 2.2 +/- 1.6; 24 months; 3.4 +/- 0.9; amitriptyline-gabapentin: 0 months, 7.6 +/- 0.8; 6 months, 1.3 +/- 0.9; 12 months, 1.7 +/- 1.0; 24 months, 2.3 +/- 0.9). Side effects were lower in the gabapentin group than in the two other groups, the difference reaching statistical significance after three months (P < 0.05). CONCLUSION: Gabapentin alone or in combination with amitriptyline is better than amitriptyline alone in the treatment of female chronic pelvic pain.

The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture.

UNLABELLED: Acupuncture is an established adjuvant analgesic modality for the treatment of chronic pain. Electrical stimulation of acupuncture points is considered to increase acupuncture analgesia. In this prospective, randomized, double-blind, controlled study we tested the hypothesis that auricular electroacupuncture (EA) relieves pain more effectively than conventional manual auricular acupuncture (CO) in chronic low back pain patients with insufficient pain relief (visual analogue scale [VAS] > or = 5) treated with standardized analgesic therapy. Disposable acupuncture needles were inserted in the auricular acupuncture points 29, 40, and 55 of the dominant side and connected to a newly developed battery-powered miniaturized stimulator worn behind the ear. Patients were randomized into group EA (n = 31) with continuous low-frequency auricular EA (1 Hz biphasic constant current of 2 mA) and group CO (n = 30) without electrical stimulation (sham-electroacupuncture). Treatment was performed once weekly for 6 wk, and in each group needles were withdrawn 48 h after insertion. During the study period and a 3-mo follow-up, patients were asked to complete the McGill questionnaire. Psychological well being, activity level, quality of sleep, and pain intensity were assessed by means of VAS; moreover, analgesic drug consumption was documented. Pain relief was significantly better in group EA during the study and the follow-up period as compared with group CO. Similarly, psychological well-being, activity, and sleep were significantly improved in group EA versus group CO, the consumption of analgesic rescue medication was less, and more patients returned to full-time employment. Neuropathic pain in particular improved in patients treated with EA. There were no adverse side effects. These results are the first to demonstrate that continuous EA stimulation of auricular acupuncture points improves the treatment of chronic low back pain in an outpatient population. IMPLICATIONS: Continuous electrical stimulation of auricular acupuncture points using the new point stimulation device P-stim significantly decreases pain intensity and improves psychological well-being, activity, and sleep in chronic low back pain patients.

Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: a pilot study.

UNLABELLED: In this prospective, randomized, double-blinded, controlled study, we tested the hypothesis that auricular electroacupuncture relieves pain more effectively than conventional manual auricular acupuncture. We studied 21 chronic cervical pain patients without radicular symptoms with insufficient pain relief (visual analogue scale >5) treated with standardized analgesic therapy. All patients received disposable acupuncture needles on the dominant side on the following acupuncture points: cervical spine, shen men, and cushion. In 10 patients, needles were continuously stimulated (2-mA constant current, 1 Hz monophasic) by using the electrical point stimulation device P-STIM. In 11 control patients, no electrical stimulation was administered. All needles were withdrawn 48 h after insertion. Acupuncture was performed once a week for 6 wk. Patients had to complete a questionnaire assessing pain intensity, psychological well-being, activity, sleep, and demand for rescue medication (lornoxicam and tramadol). The reduction in pain scores was significant in the electrical acupuncture group. Similarly, psychological well-being, activity, and sleep were significantly improved in patients receiving electrical acupuncture, and consumption of rescue medication was significantly less. These results demonstrate that continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM improves the treatment of chronic cervical pain in an outpatient population. IMPLICATIONS: Continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM significantly decreases pain intensity and significantly improves psychological well-being, activity, and sleep in chronic cervical pain patients.

Does pain relief improve pain behavior and mood in chronic pain patients?

Chronic pain is a subjective experience and has not only physical, but also psychological and social dimensions. In the present study, we sought to determine whether an effective pain reduction would improve mood, behavioral, and cognitive outcome measures in chronic pain patients. Four-hundred-seventy-seven patients entering pain therapy at our university pain center were prospectively studied during the first year of treatment. Patients received pharmacotherapy, acupuncture, transcutaneous nerve stimulation, physiotherapy, and invasive pain treatment. Intensity and quality of pain were assessed with the Visual Analog Scale and Multidimensional Pain Scale. Psychological and social aspects were evaluated using the Pain Behavior Questionnaire and the Profile of Mood States questionnaire. Significant reductions in pain intensity (Visual Analog Scale, 7.35 at pretreatment and 1.03 after 12 mo; P = 0.01; Multidimensional Pain Scale, F = 6.185; P < 0.001) were accompanied by improvements in behavioral and cognitive dimensions (Pain Behavior Questionnaire, F = 9.483; P = 0.002). However, mood and psychological well-being did not improve (Profile of Mood States, F = 0.416; P = 0.551). The authors conclude that reducing pain intensity improves behavioral and cognitive dimensions but not psychological well-being and cognitive assessment.

The influence of local active warming on pain relief of patients with cholelithiasis during rescue transport.

UNLABELLED: Upper abdominal pain, a frequent symptom of the presence of gallstone disease, is the cause of 6% of the emergency calls of the Austrian emergency system. Pain resulting from cholelithiasis is characteristically severe. Recent data show that active warming during emergency transport of trauma victims is effective in reducing pain. Therefore, we hypothesized that local active warming of the abdomen would be an effective pain treatment for patients with acute cholelithiasis and could be provided by paramedics. Sixty patients (>19 yr) consented to participate in this study. They were divided into two groups: Group 1, who received active warming of the upper abdomen with a carbon-fiber warming blanket (42 degrees C), and Group 2, who received no warming of the abdomen. Neither group received any drug-based pain care. Patients were asked to rate their pain and anxiety by using visual analog scales (VAS). Statistical evaluation was performed with Student's t-test; P < 0.05 was considered significant. In Group 1, a significant (P < 0.01) pain reduction was recorded in all cases on a visual analog scale (VAS), from 86.8 +/- 5.5 mm to 41.2 +/- 16.2 mm. In Group 2, the patients' pain scores remained comparable, from 88.3 +/- 9.9 mm to 88.1 +/- 10.0 mm on a VAS. In comparing Group 1 with Group 2 on arrival at the hospital, pain scores showed a significant difference (P < 0.01). In Group 1, the VAS score changes for anxiety were significantly reduced (P < 0.01), from 82.7 +/- 10.8 mm before treatment to 39.0 +/- 14.0 mm after treatment. In Group 2, a nonsignificant change of this score was noted, from 84.5 +/- 14.6 mm to 83.5 +/- 8.4 mm. Comparing Group 1 with Group 2 on arrival at the hospital showed a significant difference in anxiety scores (P < 0.01). We conclude that local active warming is an effective and easy-to-learn treatment for pain resulting from acute cholelithiasis in emergency care. IMPLICATIONS: Active local warming of the upper abdomen is an effective treatment for patients with cholelithiasis being transported to the hospital by paramedics who are not permitted to provide any drug-based pain care. We observed no negative side effects of this treatment.