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PURPOSE OF REVIEW: This review critically analyzes the recent literature on virtual reality's (VR) use in acute and chronic pain management, offering insights into its efficacy, applications, and limitations. RECENT FINDINGS: Recent studies, including meta-analyses and randomized controlled trials, have demonstrated VR's effectiveness in reducing pain intensity in various acute pain scenarios, such as procedural/acute pain and in chronic pain conditions. The role of factors such as immersion and presence in enhancing VR's efficacy has been emphasized. Further benefits have been identified in the use of VR for assessment as well as symptom gathering through conversational avatars. However, studies are limited, and strong conclusions will require further investigation. VR is emerging as a promising non-pharmacological intervention in pain management for acute and chronic pain. However, its long-term efficacy, particularly in chronic pain management, remains an area requiring further research. Key findings highlight that VR programs vary in efficacy depending on the specificity of the origin of pain.
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INTRODUCTION: The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS: The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS: The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS: NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.
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Terapia de Salvação , Estimulação da Medula Espinal , Humanos , Estimulação da Medula Espinal/métodos , Estimulação da Medula Espinal/normas , Terapia de Salvação/métodos , Terapia de Salvação/normas , Consenso , Resultado do Tratamento , Dor Crônica/terapiaRESUMO
INTRODUCTION: Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS: The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS: Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS: The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
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Dor Lombar , Dor Intratável , Radiculopatia , Humanos , Dor nas Costas , Dor Lombar/terapia , Região Lombossacral , Radiculopatia/terapia , Resultado do TratamentoRESUMO
OBJECTIVES: The purpose of the ongoing follow-up of ReActiv8-A clinical trial is to document the longitudinal benefits of episodic stimulation of the dorsal ramus medial branch and consequent contraction of the lumbar multifidus in patients with refractory mechanical chronic low back pain (CLBP). We report the four-year outcomes of this trial. MATERIALS AND METHODS: ReActiv8-A is a prospective, single-arm trial performed at nine sites in the United Kingdom, Belgium, and Australia. Eligible patients had disabling CLBP (low back pain Numeric Rating Scale [NRS] ≥6; Oswestry Disability Index [ODI] ≥25), no indications for spine surgery or spinal cord stimulation, and failed conventional management including at least physical therapy and medications for low back pain. Fourteen days postimplantation, stimulation parameters were programmed to elicit strong, smooth contractions of the multifidus, and participants were given instructions to activate the device for 30-min stimulation-sessions twice daily. Annual follow-up through four years included collection of NRS, ODI, and European Quality of Life Score on Five Dimensions (EQ-5D). Background on mechanisms, trial design, and one-year outcomes were previously described. RESULTS: At baseline (N = 53) (mean ± SD) age was 44 ± 10 years; duration of back pain was 14 ± 11 years, NRS was 6.8 ± 0.8, ODI 44.9 ± 10.1, and EQ-5D 0.434 ± 0.185. Mean improvements from baseline were statistically significant (p < 0.001) and clinically meaningful for all follow-ups. Patients completing year 4 follow-up, reported mean (±standard error of the mean) NRS: 3.2 ± 0.4, ODI: 23.0 ± 3.2, and EQ-5D: 0.721 ± 0.035. Moreover, 73% of participants had a clinically meaningful improvement of ≥2 points on NRS, 76% of ≥10 points on ODI, and 62.5% had a clinically meaningful improvement in both NRS and ODI and 97% were (very) satisfied with treatment. CONCLUSIONS: In participants with disabling intractable CLBP who receive long-term restorative neurostimulation, treatment satisfaction remains high and improvements in pain, disability, and quality-of-life are clinically meaningful and durable through four years.
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Dor Lombar , Adulto , Humanos , Dor Lombar/terapia , Vértebras Lombares , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Qualidade de Vida , Resultado do TratamentoRESUMO
OBJECTIVES: Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non-specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF). METHODS: This review presents the evidence for MF involvement in CLBP, mechanisms of action of disruption of control of the MF, and options for restoring control of the MF as a treatment for NSCLBP. RESULTS: Imaging assessment of motor control dysfunction of the MF in individual patients is fraught with difficulty. MRI or ultrasound imaging techniques, while reliable, have limited diagnostic or predictive utility. For some patients, restoration of motor control to the MF with specific exercises can be effective, but population results are not persuasive since most patients are unable to voluntarily contract the MF and may be inhibited from doing so due to arthrogenic muscle inhibition. CONCLUSIONS: Targeting MF control with restorative neurostimulation promises a new treatment option.
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Terapia por Exercício/métodos , Dor Lombar/reabilitação , Músculo Esquelético/fisiopatologia , Dor Crônica/reabilitação , Eletromiografia , Humanos , Vértebras Lombares/inervação , Medição da DorRESUMO
OBJECTIVES: The purpose of the international multicenter prospective single arm clinical trial was to evaluate restorative neurostimulation eliciting episodic contraction of the lumbar multifidus for treatment of chronic mechanical low back pain (CMLBP) in patients who have failed conventional therapy and are not candidates for surgery or spinal cord stimulation (SCS). MATERIALS AND METHODS: Fifty-three subjects were implanted with a neurostimulator (ReActiv8, Mainstay Medical Limited, Dublin, Ireland). Leads were positioned bilaterally with electrodes close to the medial branch of the L2 dorsal ramus nerve. The primary outcome measure was low back pain evaluated on a 10-Point Numerical Rating Scale (NRS). Responders were defined as subjects with an improvement of at least the Minimal Clinically Important Difference (MCID) of ≥2-point in low back pain NRS without a clinically meaningful increase in LBP medications at 90 days. Secondary outcome measures included Oswestry Disability Index (ODI) and Quality of Life (QoL; EQ-5D). RESULTS: For 53 subjects with an average duration of CLBP of 14 years and average NRS of 7 and for whom no other therapies had provided satisfactory pain relief, the responder rate was 58%. The percentage of subjects at 90 days, six months, and one year with ≥MCID improvement in single day NRS was 63%, 61%, and 57%, respectively. Percentage of subjects with ≥MCID improvement in ODI was 52%, 57%, and 60% while those with ≥MCID improvement in EQ-5D was 88%, 82%, and 81%. There were no unanticipated adverse events (AEs) or serious AEs related to the device, procedure, or therapy. The initial surgical approach led to a risk of lead fracture, which was mitigated by a modification to the surgical approach. CONCLUSIONS: Electrical stimulation to elicit episodic lumbar multifidus contraction is a new treatment option for CMLBP. Results demonstrate clinically important, statistically significant, and lasting improvement in pain, disability, and QoL.
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Dor Lombar/terapia , Região Lombossacral/fisiologia , Estimulação da Medula Espinal/métodos , Resultado do Tratamento , Adulto , Dor Crônica/terapia , Avaliação da Deficiência , Pessoas com Deficiência , Eletrodos Implantados , Feminino , Humanos , Cooperação Internacional , Dor Lombar/psicologia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Qualidade de Vida/psicologia , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVES: Spinal cord stimulation is an evidence-based treatment for a number of chronic pain conditions. While this therapy offers improvement in pain and function it is not without potential complications. These complications include device failure, migration, loss of therapeutic paresthesia, and infection. This article looked to establish a modern infection rate for spinal cord stimulators, assess the impact of known risk factors for surgical site infections and to determine the impact of certain preventative measures on the rate of infection. METHODS: After institutional review board approval, a multisite, retrospective review was conducted on 2737 unique implants or revisions of SCS systems. Patient demographics, risk factors including diabetes, tobacco use, obesity, revision surgery, trial length, implant location, implant type, surgeon background, prophylactic antibiotic use, utilization of a occlusive dressing, and post-operative antibiotic use were recorded and analyzed. RESULTS: The overall infection rate was 2.45% (n = 67). Diabetes, tobacco use, and obesity did not independently increase the rate of infection. Revision surgeries had a trend toward higher infection rate; however, this did not meet statistical significance. There was no difference in the rate of infection between implants performed by physicians of different base specialties, cylinder leads vs. paddle leads, or between different prophylactic antibiotics. Implants performed at academic centers had a higher rate of infection when compared to implants performed in nonacademic settings. When patients received an occlusive dressing or post-operative antibiotics they had a lower rate of infection. CONCLUSIONS: The infection rate (2.45%) reported in this study is lower than the previously reported rates (3-6%) and are on par with other surgical specialties. This study did not show an increased rate of infection for patients that used tobacco, had diabetes or were obese. It's possible that given the low overall infection rate a larger study is needed to establish the true impact of these factors on infection. In addition, this study did not address the impact of poorly controlled diabetes mellitus (elevated hemoglobin A1c) vs. well-controlled diabetes. It can be concluded from this study that utilizing an occlusive dressing over the incision in the post-operative period decreases the rate of infection and should become the standard of care. This study also demonstrated the positive impact of post-operative antibiotics in decreasing the rate of infection. Studies in other surgical specialties have not shown this impact which would suggest that further research is needed.
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Eletrodos Implantados/tendências , Contaminação de Equipamentos , Estimulação da Medula Espinal/tendências , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/etiologia , Adulto , Idoso , Antibacterianos/uso terapêutico , Eletrodos Implantados/efeitos adversos , Eletrodos Implantados/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estimulação da Medula Espinal/efeitos adversos , Estimulação da Medula Espinal/instrumentação , Infecção da Ferida Cirúrgica/tratamento farmacológicoRESUMO
INTRODUCTION: Surgical site infection is a potential complication of spinal cord stimulator (SCS) implantation. Current understanding of the epidemiology, diagnosis, and treatment of these infections is based largely on small clinical studies, many of which are outdated. Evidence-based guidelines for management of SCS-related infections thus rely instead on expert opinion, case reports, and case series. In this study, we aim to provide a large scale retrospective study of infection management techniques specifically for SCS implantation. METHODS: A multicenter retrospective study of SCS implants performed over a seven-year period at 11 unique academic and non-academic institutions in the United States. All infections and related complications in this cohort were analyzed. RESULTS: Within our study of 2737 SCS implant procedures, we identified all procedures complicated by infection (2.45%). Localized incisional pain and wound erythema were the most common presenting signs. Laboratory studies were performed in the majority of patients, but an imaging study was performed in less than half of these patients. The most common causative organism was Staphylococcus aureus and the IPG pocket was the most common site of an SCS-related infection. Explantation was ultimately performed in 52 of the 67 patients (77.6%). Non-explantation salvage therapy was attempted in 24 patients and was successful in resolving the infection in 15 patients without removal of SCS hardware components. DISCUSSION: This study provides current data regarding SCS related infections, including incidence, diagnosis, and treatment.
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Contaminação de Equipamentos , Próteses e Implantes/efeitos adversos , Estimulação da Medula Espinal/efeitos adversos , Estimulação da Medula Espinal/instrumentação , Infecção da Ferida Cirúrgica/diagnóstico , Antibacterianos/uso terapêutico , Contaminação de Equipamentos/prevenção & controle , Feminino , Seguimentos , Humanos , Próteses e Implantes/microbiologia , Estudos Retrospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/terapia , Staphylococcus aureus/isolamento & purificação , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/epidemiologiaRESUMO
OBJECTIVES: Electrical stimulation for multifidus muscle contraction is a novel approach for treating chronic low back pain (CLBP). A multicenter, open-label feasibility study investigated this modality in patients with continuing CLBP despite medical management and no prior back surgery and no known pathological cause of CLBP. METHODS: Twenty-six patients with continuing CLBP despite physical therapy and medication were implanted with commercially-available implantable pulse generators and leads positioned adjacent to the medial branch of the dorsal ramus as it crosses the L3 transverse process such that electrical stimulation resulted in contraction of the lumbar multifidus (LM) muscle. Patients self-administered stimulation twice daily for 20 min. Low back pain (VAS), Oswestry Disability Index (ODI) and Quality of Life (EQ-5D) scores were collected at three and five months and compared to baseline. Stimulation was withdrawn between months 4 and 5 to test durability of effect. RESULTS: At three months, 74% of patients met or exceeded the minimally important change (MIC) in VAS and 63% for disability. QoL improved in 84% of patients (N = 19) and none got worse. Five of the 11 patients on disability for CLBP (45%) resumed work by three months. Half the patients reported ≥50% VAS reduction by month 5. Twenty-one lead migration events occurred in 13 patients, of which 7 patients are included in the efficacy cohort. CONCLUSIONS: Episodic stimulation to induce LM contraction can reduce CLBP and disability, improve quality of life and enable return to work. A dedicated lead design to reduce risk of migration is required.
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Terapia por Estimulação Elétrica/métodos , Dor Lombar/fisiopatologia , Dor Lombar/terapia , Recuperação de Função Fisiológica/fisiologia , Adulto , Doença Crônica , Avaliação da Deficiência , Pessoas com Deficiência , Terapia por Estimulação Elétrica/instrumentação , Eletrodos Implantados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos dos Movimentos/etiologia , Transtornos dos Movimentos/terapia , Dinâmica não Linear , Medição da Dor , Resultado do Tratamento , Adulto JovemRESUMO
Increasing the durability of crop resistance to plant pathogens is one of the key goals of virulence management. Despite the recognition of the importance of demographic and environmental stochasticity on the dynamics of an epidemic, their effects on the evolution of the pathogen and durability of resistance has not received attention. We formulated a stochastic epidemiological model, based on the Kramer-Moyal expansion of the Master Equation, to investigate how random fluctuations affect the dynamics of an epidemic and how these effects feed through to the evolution of the pathogen and durability of resistance. We focused on two hypotheses: firstly, a previous deterministic model has suggested that the effect of cropping ratio (the proportion of land area occupied by the resistant crop) on the durability of crop resistance is negligible. Increasing the cropping ratio increases the area of uninfected host, but the resistance is more rapidly broken; these two effects counteract each other. We tested the hypothesis that similar counteracting effects would occur when we take account of demographic stochasticity, but found that the durability does depend on the cropping ratio. Secondly, we tested whether a superimposed external source of stochasticity (for example due to environmental variation or to intermittent fungicide application) interacts with the intrinsic demographic fluctuations and how such interaction affects the durability of resistance. We show that in the pathosystem considered here, in general large stochastic fluctuations in epidemics enhance extinction of the pathogen. This is more likely to occur at large cropping ratios and for particular frequencies of the periodic external perturbation (stochastic resonance). The results suggest possible disease control practises by exploiting the natural sources of stochasticity.
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Produtos Agrícolas/microbiologia , Modelos Teóricos , IncertezaRESUMO
The isolation and purification of protactinium from uranium materials is essential for 231Pa-235U radiochronometry, but separating Pa from uranium-niobium alloys, a common material in the nuclear fuel cycle, is challenging due to the chemical similarity of Pa and Nb. Here we present three resin chromatography separation techniques for isolating Pa from U and Nb which were independently developed by three different laboratories through ad hoc adaptations of standard operating procedures. Our results underscore the need for and value of purification methods suitable for a diversity of uranium-based materials to ensure the operational readiness of nuclear forensics laboratories. Supplementary Information: The online version contains supplementary material available at 10.1007/s10967-023-08928-y.
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The technique of lumbar medial branch radiofrequency neurotomy for facet joint pain has an intriguing history involving a diverse timeline of medical specialists. This paper aims to chart the pathway that led to its invention and the series of modifications and refinements that have led to modern practice. The story begins with the treatment of World War I soldiers by Nesfield, who used scalpels to cut "trapped" nerves. Inspired by Nesfield's treatment, Rees developed the "percutaneous rhizolysis" technique in 1960. Shealy was the first to use radiofrequency electrodes for denervation of the facet joints, introducing his technique in 1971. Several radiofrequency electrode developments came about from collaborations with Cosman medical device entrepreneurs during the 1970s, including the Shealy Rhizolysis Kit, the Ray Rhizotomy Electrode, and the Sluijter-Mehta Kit. Subsequent dissections of Rees' technique and modification of Shealy's procedure by Bogduk saw the development of "percutaneous lumbar medial branch neurotomy" in 1980 by Bogduk and Long. Bogduk continued to contribute significantly to validation, refinement and acceptance of the technique. In 1998, the technique of pulsed radiofrequency was invented by Sluijter, Cosman, Rittman and van Kleef. Subsequent innovations have consisted of cooled radiofrequency neurotomy, multi-tined cannulae, endoscopic systems, and alternative denervation targets, such as the facet joint capsule. As we pass the first 100 years of the story, we believe there are more chapters to be written on this fascinating subject.
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A workshop was held from 28 February to 2 March 2006 at the National Institute of Standards and Technology (NIST) to evaluate the needs for new directions for complex matrix reference materials certified for radionuclide content, interlaboratory comparisons and performance evaluation (PE) programs. The workshop identified new radioanalytical metrology thrust areas needed for environmental, radiobioassay, emergency consequence management, and nuclear forensics, attribution, nonproliferation, and safeguards.
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A radioactive solution of (111)Ag, standardised by the absolute measurement methods 4π(PC)-γ and 4π(LS)-γ coincidence counting at the National Physical Laboratory (NPL), was measured by two independently calibrated HPGe γ spectrometers in order to estimate the γ emission intensities and to determine the absolute intensity, with the aim of improving the currently published values. An absolute intensity value of 6.68 (7)% was obtained for the 342.1 keV γ emission, which is in agreement with previously reported values, but greatly reduces the uncertainty. Additionally, this work proposes a new emission intensity for the 450.0 keV γ emission that has not been previously reported, with an absolute intensity of 0.000482 (12)%. An investigation of the published γ emission intensities shows significant discrepancies that require resolution.
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In this paper, a novel way of developing synthetic environmental radioactivity reference materials via the sol-gel process is described. Two solid reference materials (both having a SiO(2) matrix) were synthesised by hydrolysing a liquid mixture of tetraethyl orthosilicate (TEOS), ethanol and standardised mixed radionuclide solutions. The certified values, which were in the Bqg(-1) range, for the radionuclides in the material were determined by NPL and compared with results from measurements made by 36 organisations from 17 countries using a 'consensus' approach. The measurements were made within two wider test exercises (the NPL Environmental Radioactivity Proficiency Test Exercises 2009 and 2010). Certified activity concentration values were obtained for (60)Co, (133)Ba, (134)Cs, (137)Cs, (152)Eu, (154)Eu and (241)Am and indicative values were obtained for (55)Fe and (90)Sr.
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Monitoramento de Radiação/normas , Radioisótopos/química , Radioisótopos/normas , Radiometria/normas , Meia-Vida , Internacionalidade , Doses de Radiação , Radioisótopos/análise , Padrões de Referência , Valores de ReferênciaRESUMO
A standard of (210)Pb in solution was produced at the National Physical Laboratory by a novel technique combining Cerenkov counting with the established liquid scintillation efficiency tracing technique known as the CIEMAT/NIST method. Coincidence counting was applied in order to validate the measurements and the activity concentrations of the solution determined with each technique are shown to be in agreement. Radiochemical separation of the (210)Pb from its daughters was also necessary and the scheme for the separation is described. After performing this two-stage standardisation, the uncertainty was successfully lowered to 0.66% (k=1). This uncertainty is approximately a factor of four lower than previously achieved at NPL by the classical method of standardisation of radionuclides, i.e. coincidence counting.
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Radioisótopos de Chumbo/normas , Contagem de Cintilação/métodos , Padrões de Referência , SoluçõesRESUMO
In this paper, the development of a neutron-activated concrete powder reference material is described. The material originated from core samples taken from a concrete bioshield of a decommissioned nuclear reactor which ceased operation almost 30 years ago after approximately 20 years of operation. The assigned values, which were in the Bq g(-1) range, for the radionuclides in the material were determined by a 'consensus' method from measurements made by 33 organisations from 15 countries. The measurements were made within a wider test exercise (the NPL Environmental Radioactivity Proficiency Test Exercise 2008). Assigned specific activity values were obtained for (60)Co, (133)Ba, (152)Eu and (154)Eu and indicative values were obtained for (3)H (total), (3)H (leachable), (14)C, (40)K, (55)Fe and (63)Ni.